{"id":377,"date":"2016-10-04T21:09:34","date_gmt":"2016-10-04T21:09:34","guid":{"rendered":"https:\/\/delvi.nl\/?page_id=377"},"modified":"2023-05-18T11:15:36","modified_gmt":"2023-05-18T11:15:36","slug":"aanmeldformulier","status":"publish","type":"page","link":"https:\/\/delvi.nl\/en\/practice\/registration\/registration-form\/","title":{"rendered":"Aanmeldformulier"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;section&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;2_3,1_3&#8243; admin_label=&#8221;row&#8221; _builder_version=&#8221;4.16&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;2_3&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;Text&#8221; _builder_version=&#8221;4.16&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Form 1: Registration<\/h3>\n                            <p class='gform_description'>Digitaal aanmelden kan via dit inschrijfformulier. Na aanmelding neemt de assistente binnen 3 werkdagen contact met je op voor het inplannen van een afspraak.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/en\/wp-json\/wp\/v2\/pages\/377' data-formid='1' data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/377\" >\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_1_23\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><h2 class=\"gsection_title\">Personal details<\/h2><\/li><li id=\"field_1_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub'>First name<\/label>\n                                                <\/span>\n                            <span id='input_1_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_1_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_1_4' class='gform-field-label gform-field-label--type-sub'>Preposition<\/label>\n                                                <\/span>\n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_67\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\"><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex'  ><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_67'>\n                            \n                            <span id='input_1_67_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_67.3' id='input_1_67_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_67_3' class='gform-field-label gform-field-label--type-sub'>Initials<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_1_66\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Maiden name (if applicable)<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_66'>\n                            \n                            \n                            \n                            <span id='input_1_66_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.6' id='input_1_66_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_66_6' class='gform-field-label gform-field-label--type-sub'>Maiden name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_1_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_1_2_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_2_1' id='input_1_2_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_1_2_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_2_3' id='input_1_2_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_2.4' id='input_1_2_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_1_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_1_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_2_5' id='input_1_2_5_label' class='gform-field-label gform-field-label--type-sub'>Zipcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_1_2_6' value='Netherlands' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_25\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><label class='gfield_label gform-field-label' for='input_1_25' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_1_25' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_8\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><label class='gfield_label gform-field-label' for='input_1_8' >Telephone number<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_1_8' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_7\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\"><label class='gfield_label gform-field-label' for='input_1_7' >Mobile number<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_1_7' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_5\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_1_5' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_5_2_container'>\n                                            <input type='text' maxlength='2' name='input_5[]' id='input_1_5_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_1_5_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_5_1_container'>\n                                        <input type='text' maxlength='2' name='input_5[]' id='input_1_5_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                        <label for='input_1_5_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_5_3_container'>\n                                        <input type='text' maxlength='4' name='input_5[]' id='input_1_5_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                        <label for='input_1_5_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_1_47\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\"><label class='gfield_label gform-field-label' for='input_1_47' >Burgerservicenummer (BSN)<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_1_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_24\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><label class='gfield_label gform-field-label' for='input_1_24' >Country of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_49\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\"><label class='gfield_label gform-field-label' for='input_1_49' >Nationality<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_27\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><label class='gfield_label gform-field-label' for='input_1_27' >Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_1_27' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nederlands' >Nederlands<\/option><option value='Europeide' >Europeide<\/option><option value='Noord-Afrikaans' >Noord-Afrikaans<\/option><option value='Overig Afrikaans' >Overig Afrikaans<\/option><option value='Turks' >Turks<\/option><option value='Zuid-Aziatisch' >Zuid-Aziatisch<\/option><option value='Oost- en Zuidoost Aziatisch' >Oost- en Zuidoost Aziatisch<\/option><option value='Overig Aziatisch' >Overig Aziatisch<\/option><option value='Overig Westers' >Overig Westers<\/option><option value='Overig niet Westers' >Overig niet Westers<\/option><option value='Meervoudige afkomst' >Meervoudige afkomst<\/option><\/select><\/div><\/li><li id=\"field_1_26\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><label class='gfield_label gform-field-label' for='input_1_26' >Marital status<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_1_26' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Gehuwd' >Gehuwd<\/option><option value='Samenwonend' >Samenwonend<\/option><option value='Geregistreerd partnerschap' >Geregistreerd partnerschap<\/option><option value='Alleenstaand' >Alleenstaand<\/option><option value='Gescheiden' >Gescheiden<\/option><option value='L.A.T.' >L.A.T.<\/option><option value='Overig' >Overig<\/option><\/select><\/div><\/li><li id=\"field_1_64\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\"><label class='gfield_label gform-field-label' for='input_1_64' >Godsdienst<\/label><div class='ginput_container ginput_container_select'><select name='input_64' id='input_1_64' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Rooms katholiek' >Rooms katholiek<\/option><option value='Nederlands hervormd' >Nederlands hervormd<\/option><option value='Gereformeerd' >Gereformeerd<\/option><option value='Jehova&#039;s getuige' >Jehova&#039;s getuige<\/option><option value='Islam' >Islam<\/option><option value='Hindoe' >Hindoe<\/option><option value='Christelijk' >Christelijk<\/option><option value='Protestant' >Protestant<\/option><option value='Geen' >Geen<\/option><option value='Overig' >Overig<\/option><\/select><\/div><\/li><li id=\"field_1_35\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\"><label class='gfield_label gform-field-label' for='input_1_35' >Beroep<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_36\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\"><label class='gfield_label gform-field-label' for='input_1_36' >Beroep status<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_1_36' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Full-time baan' >Full-time baan<\/option><option value='Part-time baan' >Part-time baan<\/option><option value='Werkzoekend' >Werkzoekend<\/option><option value='WAO' >WAO<\/option><option value='Niet werken, vrije keus' >Niet werken, vrije keus<\/option><option value='Onbekend' >Onbekend<\/option><\/select><\/div><\/li><li id=\"field_1_39\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_label gform-field-label' for='input_1_39' >Opleiding<\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Geen opleiding' >Geen opleiding<\/option><option value='Lager algemeen onderwijs' >Lager algemeen onderwijs<\/option><option value='Lager beroepsonderwijs (LBO)' >Lager beroepsonderwijs (LBO)<\/option><option value='Middelbaar algemeen onderwijs (MAVO\/VMBO)' >Middelbaar algemeen onderwijs (MAVO\/VMBO)<\/option><option value='Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)' >Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)<\/option><option value='Hoger algemeen onderwijs (HAVO\/VWO)' >Hoger algemeen onderwijs (HAVO\/VWO)<\/option><option value='Hoger beroepsonderwijs (HBO, inc HEAO en HTS)' >Hoger beroepsonderwijs (HBO, inc HEAO en HTS)<\/option><option value='Wetenschappelijk onderwijs (Universiteit\/hogeschool)' >Wetenschappelijk onderwijs (Universiteit\/hogeschool)<\/option><option value='Overig onderwijs' >Overig onderwijs<\/option><\/select><\/div><\/li><li id=\"field_1_28\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><label class='gfield_label gform-field-label' for='input_1_28' >Spreekt u Nederlands?<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_1_28' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Beperkt' >Beperkt<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_29\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_label gform-field-label' for='input_1_29' >Zo nee, welke taal spreekt u?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_68\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\"><label class='gfield_label gform-field-label' for='input_1_68' >Heeft u moeite met lezen en schrijven en denkt u hulp nodig te hebben bij het lezen van folders en andere informatie?<\/label><div class='ginput_container ginput_container_select'><select name='input_68' id='input_1_68' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_41\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\"><label class='gfield_label gform-field-label' for='input_1_41' >Lengte (cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_42\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label gform-field-label' for='input_1_42' >Gewicht (kg)<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_6\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><label class='gfield_label gform-field-label' for='input_1_6' >Bent u eerder cli\u00ebnte geweest in onze praktijk?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_63\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\"><label class='gfield_label gform-field-label' for='input_1_63' >Contact via?<\/label><div class='ginput_container ginput_container_select'><select name='input_63' id='input_1_63' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Huisarts' >Huisarts<\/option><option value='Gynaecoloog' >Gynaecoloog<\/option><option value='Familie' >Familie<\/option><option value='Vrienden' >Vrienden<\/option><option value='Internet' >Internet<\/option><option value='Eigen initiatief' >Eigen initiatief<\/option><option value='Anders' >Anders<\/option><\/select><\/div><\/li><li id=\"field_1_9\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><label class='gfield_label gform-field-label' for='input_1_9' >Naam van uw huisarts<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_48\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\"><label class='gfield_label gform-field-label' for='input_1_48' >Apotheek<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_10\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><label class='gfield_label gform-field-label' for='input_1_10' >Naam van uw verzekering<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_11\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\"><label class='gfield_label gform-field-label' for='input_1_11' >Polisnummer<\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_1_11' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_60\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\"><label class='gfield_label gform-field-label' for='input_1_60' >Bent u ingeschreven in het Reinier de Graaf Gasthuis?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_1_60' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_59\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\"><label class='gfield_label gform-field-label' for='input_1_59' >Zo ja: Reinier de Graaf Gasthuis patientnummer<\/label><div class='ginput_container ginput_container_number'><input name='input_59' id='input_1_59' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_30\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><h2 class=\"gsection_title\">Gegevens partner<\/h2><\/li><li id=\"field_1_31\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_1_31'>\n                            \n                            <span id='input_1_31_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_31.3' id='input_1_31_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_31_3' class='gform-field-label gform-field-label--type-sub'>Roepnaam<\/label>\n                                                <\/span>\n                            <span id='input_1_31_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_31.4' id='input_1_31_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_31_4' class='gform-field-label gform-field-label--type-sub'>Preposition<\/label>\n                                                <\/span>\n                            <span id='input_1_31_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_31.6' id='input_1_31_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_31_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_32\"  class=\"gfield gfield--type-date gfield--input-type-datedropdown field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\"><label class='gfield_label gform-field-label'  >Date of birth<\/label><div id='input_1_32' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_1_32_2_container'><select name='input_32[]' id='input_1_32_2'   aria-required='false'  ><option value=''>Dag<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_1_32_1_container'><select name='input_32[]' id='input_1_32_1'   aria-required='false'  ><option value=''>Maand<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_1_32_3_container'><select name='input_32[]' id='input_1_32_3'   aria-required='false'  ><option value=''>Jaar<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_1_33\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\"><label class='gfield_label gform-field-label' for='input_1_33' >Mobile number<\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_1_33' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_34\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><label class='gfield_label gform-field-label' for='input_1_34' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_1_34' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_38\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\"><label class='gfield_label gform-field-label' for='input_1_38' >Beroep<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_37\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\"><label class='gfield_label gform-field-label' for='input_1_37' >Beroep status<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_1_37' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Full-time baan' >Full-time baan<\/option><option value='Part-time baan' >Part-time baan<\/option><option value='Werkzoekend' >Werkzoekend<\/option><option value='WAO' >WAO<\/option><option value='Niet werken, vrije keus' >Niet werken, vrije keus<\/option><option value='Onbekend' >Onbekend<\/option><\/select><\/div><\/li><li id=\"field_1_40\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\"><label class='gfield_label gform-field-label' for='input_1_40' >Opleiding<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Geen opleiding' >Geen opleiding<\/option><option value='Lager algemeen onderwijs' >Lager algemeen onderwijs<\/option><option value='Lager beroepsonderwijs (LBO)' >Lager beroepsonderwijs (LBO)<\/option><option value='Middelbaar algemeen onderwijs (MAVO\/VMBO)' >Middelbaar algemeen onderwijs (MAVO\/VMBO)<\/option><option value='Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)' >Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)<\/option><option value='Hoger algemeen onderwijs (HAVO\/VWO)' >Hoger algemeen onderwijs (HAVO\/VWO)<\/option><option value='Hoger beroepsonderwijs (HBO, inc HEAO en HTS)' >Hoger beroepsonderwijs (HBO, inc HEAO en HTS)<\/option><option value='Wetenschappelijk onderwijs (Universiteit\/hogeschool)' >Wetenschappelijk onderwijs (Universiteit\/hogeschool)<\/option><option value='Overig onderwijs' >Overig onderwijs<\/option><\/select><\/div><\/li><li id=\"field_1_18\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><label class='gfield_label gform-field-label' for='input_1_18' >Heeft uw partner kinderen uit een eerdere relatie?<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_1_18' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_22\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><h2 class=\"gsection_title\">Gegevens zwangerschap<\/h2><\/li><li id=\"field_1_12\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><label class='gfield_label gform-field-label' for='input_1_12' >Wanneer was de eerste dag van uw laatste menstruatie?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_1_12' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='25\/04\/2026' aria-describedby=\"input_1_12_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_12_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_12' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_52\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\"><label class='gfield_label gform-field-label' for='input_1_52' >Wat is de duur van je cyclus?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_52\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_52'>Dagen<\/div><\/li><li id=\"field_1_51\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\"><label class='gfield_label gform-field-label' for='input_1_51' >Heeft u anticonceptie gebruikt voor de zwangerschap?<\/label><div class='ginput_container ginput_container_select'><select name='input_51' id='input_1_51' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_54\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\"><label class='gfield_label gform-field-label' for='input_1_54' >Zo ja, welke soort?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_54\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_54'>Contraception<\/div><\/li><li id=\"field_1_70\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\"><label class='gfield_label gform-field-label' for='input_1_70' >Hoeveel maanden heeft u kinderwens?<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_55\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\"><label class='gfield_label gform-field-label' for='input_1_55' >Datum 1e zwangerschapstest<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_55' id='input_1_55' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_1_55_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_55_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_55' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_53\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\"><label class='gfield_label gform-field-label' for='input_1_53' >1e zwangerschapstest<\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_1_53' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Positief' >Positief<\/option><option value='Negatief' >Negatief<\/option><\/select><\/div><\/li><li id=\"field_1_56\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\"><label class='gfield_label gform-field-label' for='input_1_56' >Datum 2e zwangerschapstest<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_56' id='input_1_56' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_1_56_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_56_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_56' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_58\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\"><label class='gfield_label gform-field-label' for='input_1_58' >2e zwangerschapstest<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_1_58' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Positief' >Positief<\/option><option value='Negatief' >Negatief<\/option><\/select><\/div><\/li><li id=\"field_1_61\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\"><label class='gfield_label gform-field-label' for='input_1_61' >Heeft u een fertiliteits behandeling gehad?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_1_61' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_72\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\"><label class='gfield_label gform-field-label' for='input_1_72' >Zo ja, welke?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_13\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><label class='gfield_label gform-field-label'  >Hoeveelste zwangerschap is dit voor u?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_13'>\n\t\t\t<li class='gchoice gchoice_1_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Eerste zwangerschap'  id='choice_1_13_0'    \/>\n\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Eerste zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Tweede zwangerschap'  id='choice_1_13_1'    \/>\n\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Tweede zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Derde zwangerschap'  id='choice_1_13_2'    \/>\n\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>Derde zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_3'>\n\t\t\t\t<input name='input_13' type='radio' value='Vierde zwangerschap'  id='choice_1_13_3'    \/>\n\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Vierde zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_4'>\n\t\t\t\t<input name='input_13' type='radio' value='Vijfde of volgende zwangerschap'  id='choice_1_13_4'    \/>\n\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>Vijfde of volgende zwangerschap<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_57\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\"><label class='gfield_label gform-field-label' for='input_1_57' >Hebt u ooit een miskraam of abortus gehad?<\/label><div class='ginput_container ginput_container_select'><select name='input_57' id='input_1_57' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_19\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_label gform-field-label' for='input_1_19' >Is er in DEZE zwangerschap een echo gemaakt?<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_20\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_label gform-field-label' for='input_1_20' >Komen er aangeboren of erfelijke afwijkingen voor in uw familie of in de familie van uw partner?<\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_43\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><label class='gfield_label gform-field-label' for='input_1_43' >Zo ja, graag toelichten<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_1_43' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\"><label class='gfield_label gform-field-label'  >Moeders voor Moeders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_44'>\n\t\t\t<li class='gchoice gchoice_1_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Ik geef toestemming om mijn telefoonnummer door te geven aan de consulente'  id='choice_1_44_0'    \/>\n\t\t\t\t<label for='choice_1_44_0' id='label_1_44_0' class='gform-field-label gform-field-label--type-inline'>Ik geef toestemming om mijn telefoonnummer door te geven aan de consulente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='Ik geef GEEN toestemming om mijn telefoonnummer door te geven aan de consulente'  id='choice_1_44_1'    \/>\n\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Ik geef GEEN toestemming om mijn telefoonnummer door te geven aan de consulente<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_44'>Wij ondersteunen Moeders voor Moeders, een organisatie die de kinderwens van stellen met vruchtbaarheidsproblemen vervullen. Wij willen graag uw telefoonnummer doorgeven aan de consulente van moeders voor moeders, die vrijblijvend contact met u opneemt om u hier verder over te informeren. \nwww.moedersvoormoeders.nl <\/div><\/li><li id=\"field_1_45\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\"><label class='gfield_label gform-field-label'  >Email updates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_45'>\n\t\t\t<li class='gchoice gchoice_1_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Ik wil graag informatie via email ontvangen van DelVi'  id='choice_1_45_0'    \/>\n\t\t\t\t<label for='choice_1_45_0' id='label_1_45_0' class='gform-field-label gform-field-label--type-inline'>Ik wil graag informatie via email ontvangen van DelVi<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='Ik wens GEEN informatie via email te ontvangen van DelVi'  id='choice_1_45_1'    \/>\n\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>Ik wens GEEN informatie via email te ontvangen van DelVi<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_45'>Tijdens uw zwangerschap willen wij graag extra informatie via email versturen. Deze informatie dient als aanvulling op onze zorg. \n* Let op! Wij zullen uw gegevens NOOIT delen met derde partijen. <\/div><\/li><li id=\"field_1_46\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\"><label class='gfield_label gform-field-label'  >Email updates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_46'>\n\t\t\t<li class='gchoice gchoice_1_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Mijn partner wil graag extra informatie via email ontvangen van DelVi'  id='choice_1_46_0'    \/>\n\t\t\t\t<label for='choice_1_46_0' id='label_1_46_0' class='gform-field-label gform-field-label--type-inline'>Mijn partner wil graag extra informatie via email ontvangen van DelVi<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='Mijn partner wenst GEEN extra informatie via email te ontvangen van DelVi'  id='choice_1_46_1'    \/>\n\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>Mijn partner wenst GEEN extra informatie via email te ontvangen van DelVi<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_2'>\n\t\t\t\t<input name='input_46' type='radio' value='NVT'  id='choice_1_46_2'    \/>\n\t\t\t\t<label for='choice_1_46_2' id='label_1_46_2' class='gform-field-label gform-field-label--type-inline'>NVT<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_46'>Uw partner kan er ook voor kiezen om deze extra informatie via email te ontvangen. \n* Let op! Wij zullen uw gegevens NOOIT delen met derde partijen. <\/div><\/li><li id=\"field_1_21\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><label class='gfield_label gform-field-label' for='input_1_21' >Eventuele bijzonderheden\/mededelingen\/vragen<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_1_21' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_73\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_73\"><label class='gfield_label gform-field-label' for='input_1_73' >Comments<\/label><div class='ginput_container'><input name='input_73' id='input_1_73' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_1_73'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Versturen'  onclick='if(window[\"gf_submitting_1\"]){return false;}  window[\"gf_submitting_1\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} window[\"gf_submitting_1\"]=true;  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsImIzODJiMzc5YmUzYTJjN2I1YWZlYWRjZTM1NTdjYWRiIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n                        <\/div><script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}, 50);}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [1, current_page]);gform.utils.trigger({ event: 'gform\/postRender', native: false, data: { formId: 1, currentPage: current_page } });} );} );\n<\/script>\n\n<p>[\/et_pb_text][et_pb_text admin_label=&#8221;Text&#8221; _builder_version=&#8221;4.19.4&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Form 1. Registration<\/h3>\n                            <p class='gform_description'>You can register with us online by filling in this registration form. Once we have received your registration our assistant will contact you within 3 working days to schedule an appointment.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/377' data-formid='2' data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/377\" >\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_1\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\"><h2 class=\"gsection_title\">Personal details<\/h2><\/li><li id=\"field_2_2\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_2'>\n                            \n                            <span id='input_2_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_2_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_7\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Initials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_2_7'>\n                            \n                            <span id='input_2_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_2_7_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_7_3' class='gform-field-label gform-field-label--type-sub'>Initials<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_2_61\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_61\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Maiden name (if applicable)<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_2_61'>\n                            \n                            \n                            \n                            <span id='input_2_61_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_61.6' id='input_2_61_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_61_6' class='gform-field-label gform-field-label--type-sub'>Maiden name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_3\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_2_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_2_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_3_1' id='input_2_3_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_3' id='input_2_3_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_3.4' id='input_2_3_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_2_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_2_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_5' id='input_2_3_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_2_3_6_container' >\n                                        <select name='input_3.6' id='input_2_3_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' selected='selected'>Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_3_6' id='input_2_3_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_4\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\"><label class='gfield_label gform-field-label' for='input_2_4' >Telephone number<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_42\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_42\"><label class='gfield_label gform-field-label' for='input_2_42' >Mobile number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_2_42' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_6\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_2_6' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_6_2_container'>\n                                            <input type='text' maxlength='2' name='input_6[]' id='input_2_6_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_2_6_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_6_1_container'>\n                                        <input type='text' maxlength='2' name='input_6[]' id='input_2_6_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                        <label for='input_2_6_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_6_3_container'>\n                                        <input type='text' maxlength='4' name='input_6[]' id='input_2_6_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                        <label for='input_2_6_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_2_5\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\"><label class='gfield_label gform-field-label' for='input_2_5' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_16\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\"><label class='gfield_label gform-field-label' for='input_2_16' >Burgerservicenummer (BSN)<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_8\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Country of birth<\/label>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_2_8' >\n                        <input type='hidden' class='gform_hidden' name='input_8.4' id='input_2_8_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_2_8_6_container' >\n                                        <select name='input_8.6' id='input_2_8_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_8_6' id='input_2_8_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_44\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_44\"><label class='gfield_label gform-field-label' for='input_2_44' >Nationality<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_2_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_45\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_45\"><label class='gfield_label gform-field-label' for='input_2_45' >Ethnicity<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_62\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_62\"><label class='gfield_label gform-field-label'  >Marital status<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_62'>\n\t\t\t<li class='gchoice gchoice_2_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Married'  id='choice_2_62_0'    \/>\n\t\t\t\t<label for='choice_2_62_0' id='label_2_62_0' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='Living together'  id='choice_2_62_1'    \/>\n\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1' class='gform-field-label gform-field-label--type-inline'>Living together<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_2'>\n\t\t\t\t<input name='input_62' type='radio' value='Registered partnership'  id='choice_2_62_2'    \/>\n\t\t\t\t<label for='choice_2_62_2' id='label_2_62_2' class='gform-field-label gform-field-label--type-inline'>Registered partnership<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_3'>\n\t\t\t\t<input name='input_62' type='radio' value='Single'  id='choice_2_62_3'    \/>\n\t\t\t\t<label for='choice_2_62_3' id='label_2_62_3' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_4'>\n\t\t\t\t<input name='input_62' type='radio' value='Divorced'  id='choice_2_62_4'    \/>\n\t\t\t\t<label for='choice_2_62_4' id='label_2_62_4' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_5'>\n\t\t\t\t<input name='input_62' type='radio' value='gf_other_choice'  id='choice_2_62_5'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_62_other' name='input_62_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_63\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_63\"><label class='gfield_label gform-field-label'  >Religion<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_63'>\n\t\t\t<li class='gchoice gchoice_2_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='None'  id='choice_2_63_0'    \/>\n\t\t\t\t<label for='choice_2_63_0' id='label_2_63_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='Roman Catholic'  id='choice_2_63_1'    \/>\n\t\t\t\t<label for='choice_2_63_1' id='label_2_63_1' class='gform-field-label gform-field-label--type-inline'>Roman Catholic<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_2'>\n\t\t\t\t<input name='input_63' type='radio' value='Christian'  id='choice_2_63_2'    \/>\n\t\t\t\t<label for='choice_2_63_2' id='label_2_63_2' class='gform-field-label gform-field-label--type-inline'>Christian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_3'>\n\t\t\t\t<input name='input_63' type='radio' value='Jehovah&#039;s witness'  id='choice_2_63_3'    \/>\n\t\t\t\t<label for='choice_2_63_3' id='label_2_63_3' class='gform-field-label gform-field-label--type-inline'>Jehovah's witness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_4'>\n\t\t\t\t<input name='input_63' type='radio' value='Islam'  id='choice_2_63_4'    \/>\n\t\t\t\t<label for='choice_2_63_4' id='label_2_63_4' class='gform-field-label gform-field-label--type-inline'>Islam<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_5'>\n\t\t\t\t<input name='input_63' type='radio' value='Hindu'  id='choice_2_63_5'    \/>\n\t\t\t\t<label for='choice_2_63_5' id='label_2_63_5' class='gform-field-label gform-field-label--type-inline'>Hindu<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_6'>\n\t\t\t\t<input name='input_63' type='radio' value='Protestant'  id='choice_2_63_6'    \/>\n\t\t\t\t<label for='choice_2_63_6' id='label_2_63_6' class='gform-field-label gform-field-label--type-inline'>Protestant<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_7'>\n\t\t\t\t<input name='input_63' type='radio' value='gf_other_choice'  id='choice_2_63_7'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_63_other' name='input_63_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_12\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\"><label class='gfield_label gform-field-label' for='input_2_12' >Employment status<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_12[]' id='input_2_12' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Employed Full-Time' >Employed Full-Time<\/option><option value='Employed Part-Time' >Employed Part-Time<\/option><option value='Self-employed' >Self-employed<\/option><option value='Not employed but looking for work' >Not employed but looking for work<\/option><option value='Not employed and not looking for work' >Not employed and not looking for work<\/option><option value='Homemaker' >Homemaker<\/option><option value='Retired' >Retired<\/option><option value='Student' >Student<\/option><option value='Prefer Not to Answer' >Prefer Not to Answer<\/option><\/select><\/div><\/li><li id=\"field_2_13\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\"><label class='gfield_label gform-field-label' for='input_2_13' >Profession<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_13[]' id='input_2_13' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Accounting\/Finance' >Accounting\/Finance<\/option><option value='Advertising\/Public Relations' >Advertising\/Public Relations<\/option><option value='Aerospace\/Aviation' >Aerospace\/Aviation<\/option><option value='Arts\/Entertainment\/Publishing' >Arts\/Entertainment\/Publishing<\/option><option value='Automotive' >Automotive<\/option><option value='Banking\/Mortgage' >Banking\/Mortgage<\/option><option value='Business Development' >Business Development<\/option><option value='Business Opportunity' >Business Opportunity<\/option><option value='Clerical\/Administrative' >Clerical\/Administrative<\/option><option value='Construction\/Facilities' >Construction\/Facilities<\/option><option value='Consumer Goods' >Consumer Goods<\/option><option value='Customer Service' >Customer Service<\/option><option value='Education\/Training' >Education\/Training<\/option><option value='Energy\/Utilities' >Energy\/Utilities<\/option><option value='Engineering' >Engineering<\/option><option value='Government\/Military' >Government\/Military<\/option><option value='Green' >Green<\/option><option value='Healthcare' >Healthcare<\/option><option value='Hospitality\/Travel' >Hospitality\/Travel<\/option><option value='Human Resources' >Human Resources<\/option><option value='Installation\/Maintenance' >Installation\/Maintenance<\/option><option value='Insurance' >Insurance<\/option><option value='Internet' >Internet<\/option><option value='Job Search Aids' >Job Search Aids<\/option><option value='Law Enforcement\/Security' >Law Enforcement\/Security<\/option><option value='Legal' >Legal<\/option><option value='Management\/Executive' >Management\/Executive<\/option><option value='Manufacturing\/Operations' >Manufacturing\/Operations<\/option><option value='Marketing' >Marketing<\/option><option value='Non-Profit\/Volunteer' >Non-Profit\/Volunteer<\/option><option value='Pharmaceutical\/Biotech' >Pharmaceutical\/Biotech<\/option><option value='Professional Services' >Professional Services<\/option><option value='QA\/Quality Control' >QA\/Quality Control<\/option><option value='Real Estate' >Real Estate<\/option><option value='Restaurant\/Food Service' >Restaurant\/Food Service<\/option><option value='Retail' >Retail<\/option><option value='Sales' >Sales<\/option><option value='Science\/Research' >Science\/Research<\/option><option value='Skilled Labor' >Skilled Labor<\/option><option value='Technology' >Technology<\/option><option value='Telecommunications' >Telecommunications<\/option><option value='Transportation\/Logistics' >Transportation\/Logistics<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_14\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\"><label class='gfield_label gform-field-label' for='input_2_14' >Education<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_14[]' id='input_2_14' class='medium gfield_select'   aria-invalid=\"false\"  aria-describedby=\"gfield_description_2_14\"><option value='High School' >High School<\/option><option value='College' >College<\/option><option value='Bachelor&#039;s Degree' >Bachelor&#039;s Degree<\/option><option value='Masters' >Masters<\/option><option value='PhD' >PhD<\/option><option value='Other' >Other<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_14'>Highest level of qualification achieved<\/div><\/li><li id=\"field_2_43\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_43\"><label class='gfield_label gform-field-label' for='input_2_43' >If not, which language(s) do you speak?<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_15\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\"><label class='gfield_label gform-field-label' for='input_2_15' >Do you speak Dutch?<\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_2_15' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='A little' >A little<\/option><\/select><\/div><\/li><li id=\"field_2_17\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\"><label class='gfield_label gform-field-label' for='input_2_17' >Height (cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_18\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\"><label class='gfield_label gform-field-label' for='input_2_18' >Weight (kg)<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_19\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\"><label class='gfield_label gform-field-label' for='input_2_19' >Have you been a client in our practice previously?<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_2_19' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_2_20\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\"><label class='gfield_label gform-field-label' for='input_2_20' >Who is your GP? (Family doctor)<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_46\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><label class='gfield_label gform-field-label' for='input_2_46' >Which chemist are you registered with?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_46\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_2_46'>Apotheek<\/div><\/li><li id=\"field_2_21\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\"><label class='gfield_label gform-field-label' for='input_2_21' >Health insurance company<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_22\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\"><label class='gfield_label gform-field-label' for='input_2_22' >Health insurance policy number<\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_2_22' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_2_48\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_48\"><label class='gfield_label gform-field-label'  >Are you registered with the Reinier de Graaf hospital?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_48'>\n\t\t\t<li class='gchoice gchoice_2_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_2_48_0'    \/>\n\t\t\t\t<label for='choice_2_48_0' id='label_2_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_2_48_1'    \/>\n\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_47\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_47\"><label class='gfield_label gform-field-label' for='input_2_47' >If yes, what is your Reinier de Graaf patient number?<\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_2_47' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_2_23\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\"><h2 class=\"gsection_title\">Partner&#039;s details<\/h2><\/li><li id=\"field_2_24\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_24'>\n                            \n                            <span id='input_2_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_2_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_2_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_25\"  class=\"gfield gfield--type-date gfield--input-type-datefield field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of birth<\/label><div id='input_2_25' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_25_2_container'>\n                                            <input type='text' maxlength='2' name='input_25[]' id='input_2_25_2' value=''   aria-required='false'   placeholder='DD' \/>\n                                            <label for='input_2_25_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_25_1_container'>\n                                        <input type='text' maxlength='2' name='input_25[]' id='input_2_25_1' value=''   aria-required='false'   placeholder='MM' \/>\n                                        <label for='input_2_25_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_25_3_container'>\n                                        <input type='text' maxlength='4' name='input_25[]' id='input_2_25_3' value=''   aria-required='false'   placeholder='YYYY'   \/>\n                                        <label for='input_2_25_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_2_26\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\"><label class='gfield_label gform-field-label' for='input_2_26' >Telephone number<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_2_26' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_27\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\"><label class='gfield_label gform-field-label' for='input_2_27' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_27' id='input_2_27' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_28\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\"><label class='gfield_label gform-field-label' for='input_2_28' >Profession<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_28[]' id='input_2_28' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Accounting\/Finance' >Accounting\/Finance<\/option><option value='Advertising\/Public Relations' >Advertising\/Public Relations<\/option><option value='Aerospace\/Aviation' >Aerospace\/Aviation<\/option><option value='Arts\/Entertainment\/Publishing' >Arts\/Entertainment\/Publishing<\/option><option value='Automotive' >Automotive<\/option><option value='Banking\/Mortgage' >Banking\/Mortgage<\/option><option value='Business Development' >Business Development<\/option><option value='Business Opportunity' >Business Opportunity<\/option><option value='Clerical\/Administrative' >Clerical\/Administrative<\/option><option value='Construction\/Facilities' >Construction\/Facilities<\/option><option value='Consumer Goods' >Consumer Goods<\/option><option value='Customer Service' >Customer Service<\/option><option value='Education\/Training' >Education\/Training<\/option><option value='Energy\/Utilities' >Energy\/Utilities<\/option><option value='Engineering' >Engineering<\/option><option value='Government\/Military' >Government\/Military<\/option><option value='Green' >Green<\/option><option value='Healthcare' >Healthcare<\/option><option value='Hospitality\/Travel' >Hospitality\/Travel<\/option><option value='Human Resources' >Human Resources<\/option><option value='Installation\/Maintenance' >Installation\/Maintenance<\/option><option value='Insurance' >Insurance<\/option><option value='Internet' >Internet<\/option><option value='Job Search Aids' >Job Search Aids<\/option><option value='Law Enforcement\/Security' >Law Enforcement\/Security<\/option><option value='Legal' >Legal<\/option><option value='Management\/Executive' >Management\/Executive<\/option><option value='Manufacturing\/Operations' >Manufacturing\/Operations<\/option><option value='Marketing' >Marketing<\/option><option value='Non-Profit\/Volunteer' >Non-Profit\/Volunteer<\/option><option value='Pharmaceutical\/Biotech' >Pharmaceutical\/Biotech<\/option><option value='Professional Services' >Professional Services<\/option><option value='QA\/Quality Control' >QA\/Quality Control<\/option><option value='Real Estate' >Real Estate<\/option><option value='Restaurant\/Food Service' >Restaurant\/Food Service<\/option><option value='Retail' >Retail<\/option><option value='Sales' >Sales<\/option><option value='Science\/Research' >Science\/Research<\/option><option value='Skilled Labor' >Skilled Labor<\/option><option value='Technology' >Technology<\/option><option value='Telecommunications' >Telecommunications<\/option><option value='Transportation\/Logistics' >Transportation\/Logistics<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_29\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\"><label class='gfield_label gform-field-label' for='input_2_29' >Employment status<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_29[]' id='input_2_29' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Employed Full-Time' >Employed Full-Time<\/option><option value='Employed Part-Time' >Employed Part-Time<\/option><option value='Self-employed' >Self-employed<\/option><option value='Not employed but looking for work' >Not employed but looking for work<\/option><option value='Not employed and not looking for work' >Not employed and not looking for work<\/option><option value='Homemaker' >Homemaker<\/option><option value='Retired' >Retired<\/option><option value='Student' >Student<\/option><option value='Prefer Not to Answer' >Prefer Not to Answer<\/option><\/select><\/div><\/li><li id=\"field_2_49\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_49\"><label class='gfield_label gform-field-label' for='input_2_49' >Education<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_49[]' id='input_2_49' class='medium gfield_select'   aria-invalid=\"false\"  aria-describedby=\"gfield_description_2_49\"><option value='High School' >High School<\/option><option value='College' >College<\/option><option value='Bachelor&#039;s Degree' >Bachelor&#039;s Degree<\/option><option value='Masters' >Masters<\/option><option value='PhD' >PhD<\/option><option value='Other' >Other<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_49'>Highest level of qualification achieved<\/div><\/li><li id=\"field_2_50\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_50\"><label class='gfield_label gform-field-label'  >Does your partner have children from a previous relationship?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_50'>\n\t\t\t<li class='gchoice gchoice_2_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_2_50_0'    \/>\n\t\t\t\t<label for='choice_2_50_0' id='label_2_50_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_2_50_1'    \/>\n\t\t\t\t<label for='choice_2_50_1' id='label_2_50_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_30\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\"><h2 class=\"gsection_title\">Pregnancy details<\/h2><\/li><li id=\"field_2_31\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_31\"><label class='gfield_label gform-field-label' for='input_2_31' >When was the first day of your last period?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_31' id='input_2_31' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_2_31_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_31_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_31' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_51\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\"><label class='gfield_label gform-field-label' for='input_2_51' >How long is your cycle?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_51' id='input_2_51' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_2_51_date_format gfield_description_2_51\" aria-invalid=\"false\" \/>\n                            <span id='input_2_51_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_51' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_2_51'>number of days between periods (eg. 28) <\/div><\/li><li id=\"field_2_53\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\"><label class='gfield_label gform-field-label'  >Were you using contraception before your pregnancy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_53'>\n\t\t\t<li class='gchoice gchoice_2_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_2_53_0'    \/>\n\t\t\t\t<label for='choice_2_53_0' id='label_2_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_2_53_1'    \/>\n\t\t\t\t<label for='choice_2_53_1' id='label_2_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_64\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_64\"><label class='gfield_label gform-field-label' for='input_2_64' >If yes, what type of contraception were you using?<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_2_64' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_56\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_56\"><label class='gfield_label gform-field-label' for='input_2_56' >Date of first pregnancy test<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_56' id='input_2_56' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_2_56_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_56_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_56' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_32\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\"><label class='gfield_label gform-field-label'  >Result<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_32'>\n\t\t\t<li class='gchoice gchoice_2_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Positive'  id='choice_2_32_0'    \/>\n\t\t\t\t<label for='choice_2_32_0' id='label_2_32_0' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Negative'  id='choice_2_32_1'    \/>\n\t\t\t\t<label for='choice_2_32_1' id='label_2_32_1' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_55\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\"><label class='gfield_label gform-field-label' for='input_2_55' >Date of second pregnancy test<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_55' id='input_2_55' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_2_55_date_format gfield_description_2_55\" aria-invalid=\"false\" \/>\n                            <span id='input_2_55_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_55' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_2_55'>if you have done one<\/div><\/li><li id=\"field_2_58\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_58\"><label class='gfield_label gform-field-label'  >Result<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_58'>\n\t\t\t<li class='gchoice gchoice_2_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Positive'  id='choice_2_58_0'    \/>\n\t\t\t\t<label for='choice_2_58_0' id='label_2_58_0' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='Negative'  id='choice_2_58_1'    \/>\n\t\t\t\t<label for='choice_2_58_1' id='label_2_58_1' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_59\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_59\"><label class='gfield_label gform-field-label'  >Have you received any form of fertility treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_59'>\n\t\t\t<li class='gchoice gchoice_2_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='No'  id='choice_2_59_0'    \/>\n\t\t\t\t<label for='choice_2_59_0' id='label_2_59_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='Yes'  id='choice_2_59_1'    \/>\n\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_36\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_36\"><label class='gfield_label gform-field-label' for='input_2_36' >If yes, please tell us more about this treatment?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_2_36' class='textarea medium'  aria-describedby=\"gfield_description_2_36\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_2_36'>treatment type, dates and health care provider <\/div><\/li><li id=\"field_2_57\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\"><label class='gfield_label gform-field-label'  >What number pregnancy is this for you?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_57'>\n\t\t\t<li class='gchoice gchoice_2_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='First pregnancy'  id='choice_2_57_0'    \/>\n\t\t\t\t<label for='choice_2_57_0' id='label_2_57_0' class='gform-field-label gform-field-label--type-inline'>First pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Second pregnancy'  id='choice_2_57_1'    \/>\n\t\t\t\t<label for='choice_2_57_1' id='label_2_57_1' class='gform-field-label gform-field-label--type-inline'>Second pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_2'>\n\t\t\t\t<input name='input_57' type='radio' value='Third pregnancy'  id='choice_2_57_2'    \/>\n\t\t\t\t<label for='choice_2_57_2' id='label_2_57_2' class='gform-field-label gform-field-label--type-inline'>Third pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_3'>\n\t\t\t\t<input name='input_57' type='radio' value='Fourth pregnancy'  id='choice_2_57_3'    \/>\n\t\t\t\t<label for='choice_2_57_3' id='label_2_57_3' class='gform-field-label gform-field-label--type-inline'>Fourth pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_4'>\n\t\t\t\t<input name='input_57' type='radio' value='Fifth or subsequent pregnancy'  id='choice_2_57_4'    \/>\n\t\t\t\t<label for='choice_2_57_4' id='label_2_57_4' class='gform-field-label gform-field-label--type-inline'>Fifth or subsequent pregnancy<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_52\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_52\"><label class='gfield_label gform-field-label' for='input_2_52' >Have you ever had a miscarriage or termination?<\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_2_52' class='medium gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_2_34\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><label class='gfield_label gform-field-label' for='input_2_34' >Have you had an ultrasound scan in THIS pregnancy?<\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_2_34' class='medium gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_2_35\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\"><label class='gfield_label gform-field-label' for='input_2_35' >Is there a history of hereditary disease(s) in your family, or your partner&#039;s family?<\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_2_35' class='medium gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_2_37\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_37\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Moeders voor Moeders<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_37'><li class='gchoice gchoice_2_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='I would prefer NOT to have my telephone number passed on to Moeders voor Moeders'  id='choice_2_37_1'   aria-describedby=\"gfield_description_2_37\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_37_1' id='label_2_37_1' class='gform-field-label gform-field-label--type-inline'>I would prefer NOT to have my telephone number passed on to Moeders voor Moeders<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_37'>We actively support the Mother's for Mother's initiative that helps women with fertility issues to be able to get pregnant. To this end we would like to pass on your telephone number to the local representative who will contact you to give you further information about this initiative (with no obligation).  We encourage you to consider helping this worthy cause, however, if you prefer not to be contacted, please check the box. \nwww.moedersvoormoeders.nl <\/div><\/li><li id=\"field_2_39\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\"><label class='gfield_label gform-field-label'  >Email updates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_39'>\n\t\t\t<li class='gchoice gchoice_2_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='I agree to receiving information via email from DelVi during my pregnancy'  id='choice_2_39_0'    \/>\n\t\t\t\t<label for='choice_2_39_0' id='label_2_39_0' class='gform-field-label gform-field-label--type-inline'>I agree to receiving information via email from DelVi during my pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='I do not wish to receive information via email from DelVi during my pregnancy'  id='choice_2_39_1'    \/>\n\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1' class='gform-field-label gform-field-label--type-inline'>I do not wish to receive information via email from DelVi during my pregnancy<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_39'>We will send you email updates with relevant information during your pregnancy as part of the care you receive in our midwifery centre. \n*Please note - this information is purely to support our care and we will never pass your details on to third parties. <\/div><\/li><li id=\"field_2_60\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\"><label class='gfield_label gform-field-label' for='input_2_60' >If yes, please tell us more information<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_2_60' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_41\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_41\"><label class='gfield_label gform-field-label'  >Email updates partner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_41'>\n\t\t\t<li class='gchoice gchoice_2_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='My partner wishes to receive email updates from DelVi during my pregnancy'  id='choice_2_41_0'    \/>\n\t\t\t\t<label for='choice_2_41_0' id='label_2_41_0' class='gform-field-label gform-field-label--type-inline'>My partner wishes to receive email updates from DelVi during my pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='My partner does not wish to receive email updates from DelVi during my pregnancy'  id='choice_2_41_1'    \/>\n\t\t\t\t<label for='choice_2_41_1' id='label_2_41_1' class='gform-field-label gform-field-label--type-inline'>My partner does not wish to receive email updates from DelVi during my pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_41_2'>\n\t\t\t\t<input name='input_41' type='radio' value='Not applicable'  id='choice_2_41_2'    \/>\n\t\t\t\t<label for='choice_2_41_2' id='label_2_41_2' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_41'>Your partner can also choose to receive our email updates throughout your pregnancy, this can help when preparing and planning together. \n*Please note - this information is purely to support our care and we will never pass your details on to third parties. <\/div><\/li><li id=\"field_2_40\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_40\"><label class='gfield_label gform-field-label' for='input_2_40' >Any further information\/questions<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_2_40' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_65\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_65\"><label class='gfield_label gform-field-label' for='input_2_65' >Comments<\/label><div class='ginput_container'><input name='input_65' id='input_2_65' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_2_65'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_2\"]){return false;}  window[\"gf_submitting_2\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_2\"]){return false;} window[\"gf_submitting_2\"]=true;  jQuery(\"#gform_2\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsImIzODJiMzc5YmUzYTJjN2I1YWZlYWRjZTM1NTdjYWRiIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n                        <\/div><script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}, 50);}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [2, current_page]);gform.utils.trigger({ event: 'gform\/postRender', native: false, data: { formId: 2, currentPage: current_page } });} );} );\n<\/script>\n\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_3&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>","protected":false},"excerpt":{"rendered":"<p>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='1' id='gform_wrapper_1' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Form 1: Registration<\/h3>\n                            <p class='gform_description'>Digitaal aanmelden kan via dit inschrijfformulier. Na aanmelding neemt de assistente binnen 3 werkdagen contact met je op voor het inplannen van een afspraak.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/en\/wp-json\/wp\/v2\/pages\/377' data-formid='1' data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/377\" >\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_1_23\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><h2 class=\"gsection_title\">Personal details<\/h2><\/li><li id=\"field_1_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub'>First name<\/label>\n                                                <\/span>\n                            <span id='input_1_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_1_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_1_4' class='gform-field-label gform-field-label--type-sub'>Preposition<\/label>\n                                                <\/span>\n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_67\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\"><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex'  ><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_67'>\n                            \n                            <span id='input_1_67_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_67.3' id='input_1_67_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_67_3' class='gform-field-label gform-field-label--type-sub'>Initials<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_1_66\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Maiden name (if applicable)<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_66'>\n                            \n                            \n                            \n                            <span id='input_1_66_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.6' id='input_1_66_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_66_6' class='gform-field-label gform-field-label--type-sub'>Maiden name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_1_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_1_2_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_2_1' id='input_1_2_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_1_2_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_2_3' id='input_1_2_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_2.4' id='input_1_2_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_1_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_1_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_2_5' id='input_1_2_5_label' class='gform-field-label gform-field-label--type-sub'>Zipcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_1_2_6' value='Netherlands' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_25\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><label class='gfield_label gform-field-label' for='input_1_25' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_25' id='input_1_25' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_8\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\"><label class='gfield_label gform-field-label' for='input_1_8' >Telephone number<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_1_8' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_7\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\"><label class='gfield_label gform-field-label' for='input_1_7' >Mobile number<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_1_7' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_5\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_1_5' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_1_5_2_container'>\n                                            <input type='text' maxlength='2' name='input_5[]' id='input_1_5_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_1_5_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_5_1_container'>\n                                        <input type='text' maxlength='2' name='input_5[]' id='input_1_5_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                        <label for='input_1_5_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_1_5_3_container'>\n                                        <input type='text' maxlength='4' name='input_5[]' id='input_1_5_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                        <label for='input_1_5_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_1_47\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\"><label class='gfield_label gform-field-label' for='input_1_47' >Burgerservicenummer (BSN)<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_1_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_24\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><label class='gfield_label gform-field-label' for='input_1_24' >Country of birth<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_49\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\"><label class='gfield_label gform-field-label' for='input_1_49' >Nationality<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_27\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><label class='gfield_label gform-field-label' for='input_1_27' >Ethnicity<\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_1_27' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nederlands' >Nederlands<\/option><option value='Europeide' >Europeide<\/option><option value='Noord-Afrikaans' >Noord-Afrikaans<\/option><option value='Overig Afrikaans' >Overig Afrikaans<\/option><option value='Turks' >Turks<\/option><option value='Zuid-Aziatisch' >Zuid-Aziatisch<\/option><option value='Oost- en Zuidoost Aziatisch' >Oost- en Zuidoost Aziatisch<\/option><option value='Overig Aziatisch' >Overig Aziatisch<\/option><option value='Overig Westers' >Overig Westers<\/option><option value='Overig niet Westers' >Overig niet Westers<\/option><option value='Meervoudige afkomst' >Meervoudige afkomst<\/option><\/select><\/div><\/li><li id=\"field_1_26\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><label class='gfield_label gform-field-label' for='input_1_26' >Marital status<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_1_26' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Gehuwd' >Gehuwd<\/option><option value='Samenwonend' >Samenwonend<\/option><option value='Geregistreerd partnerschap' >Geregistreerd partnerschap<\/option><option value='Alleenstaand' >Alleenstaand<\/option><option value='Gescheiden' >Gescheiden<\/option><option value='L.A.T.' >L.A.T.<\/option><option value='Overig' >Overig<\/option><\/select><\/div><\/li><li id=\"field_1_64\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\"><label class='gfield_label gform-field-label' for='input_1_64' >Godsdienst<\/label><div class='ginput_container ginput_container_select'><select name='input_64' id='input_1_64' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Rooms katholiek' >Rooms katholiek<\/option><option value='Nederlands hervormd' >Nederlands hervormd<\/option><option value='Gereformeerd' >Gereformeerd<\/option><option value='Jehova&#039;s getuige' >Jehova&#039;s getuige<\/option><option value='Islam' >Islam<\/option><option value='Hindoe' >Hindoe<\/option><option value='Christelijk' >Christelijk<\/option><option value='Protestant' >Protestant<\/option><option value='Geen' >Geen<\/option><option value='Overig' >Overig<\/option><\/select><\/div><\/li><li id=\"field_1_35\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\"><label class='gfield_label gform-field-label' for='input_1_35' >Beroep<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_36\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\"><label class='gfield_label gform-field-label' for='input_1_36' >Beroep status<\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_1_36' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Full-time baan' >Full-time baan<\/option><option value='Part-time baan' >Part-time baan<\/option><option value='Werkzoekend' >Werkzoekend<\/option><option value='WAO' >WAO<\/option><option value='Niet werken, vrije keus' >Niet werken, vrije keus<\/option><option value='Onbekend' >Onbekend<\/option><\/select><\/div><\/li><li id=\"field_1_39\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_label gform-field-label' for='input_1_39' >Opleiding<\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_1_39' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Geen opleiding' >Geen opleiding<\/option><option value='Lager algemeen onderwijs' >Lager algemeen onderwijs<\/option><option value='Lager beroepsonderwijs (LBO)' >Lager beroepsonderwijs (LBO)<\/option><option value='Middelbaar algemeen onderwijs (MAVO\/VMBO)' >Middelbaar algemeen onderwijs (MAVO\/VMBO)<\/option><option value='Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)' >Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)<\/option><option value='Hoger algemeen onderwijs (HAVO\/VWO)' >Hoger algemeen onderwijs (HAVO\/VWO)<\/option><option value='Hoger beroepsonderwijs (HBO, inc HEAO en HTS)' >Hoger beroepsonderwijs (HBO, inc HEAO en HTS)<\/option><option value='Wetenschappelijk onderwijs (Universiteit\/hogeschool)' >Wetenschappelijk onderwijs (Universiteit\/hogeschool)<\/option><option value='Overig onderwijs' >Overig onderwijs<\/option><\/select><\/div><\/li><li id=\"field_1_28\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><label class='gfield_label gform-field-label' for='input_1_28' >Spreekt u Nederlands?<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_1_28' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Beperkt' >Beperkt<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_29\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_label gform-field-label' for='input_1_29' >Zo nee, welke taal spreekt u?<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_68\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\"><label class='gfield_label gform-field-label' for='input_1_68' >Heeft u moeite met lezen en schrijven en denkt u hulp nodig te hebben bij het lezen van folders en andere informatie?<\/label><div class='ginput_container ginput_container_select'><select name='input_68' id='input_1_68' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_41\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\"><label class='gfield_label gform-field-label' for='input_1_41' >Lengte (cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_42\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><label class='gfield_label gform-field-label' for='input_1_42' >Gewicht (kg)<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_6\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\"><label class='gfield_label gform-field-label' for='input_1_6' >Bent u eerder cli\u00ebnte geweest in onze praktijk?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_63\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\"><label class='gfield_label gform-field-label' for='input_1_63' >Contact via?<\/label><div class='ginput_container ginput_container_select'><select name='input_63' id='input_1_63' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Huisarts' >Huisarts<\/option><option value='Gynaecoloog' >Gynaecoloog<\/option><option value='Familie' >Familie<\/option><option value='Vrienden' >Vrienden<\/option><option value='Internet' >Internet<\/option><option value='Eigen initiatief' >Eigen initiatief<\/option><option value='Anders' >Anders<\/option><\/select><\/div><\/li><li id=\"field_1_9\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\"><label class='gfield_label gform-field-label' for='input_1_9' >Naam van uw huisarts<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_48\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\"><label class='gfield_label gform-field-label' for='input_1_48' >Apotheek<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_10\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\"><label class='gfield_label gform-field-label' for='input_1_10' >Naam van uw verzekering<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_11\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\"><label class='gfield_label gform-field-label' for='input_1_11' >Polisnummer<\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_1_11' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_60\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\"><label class='gfield_label gform-field-label' for='input_1_60' >Bent u ingeschreven in het Reinier de Graaf Gasthuis?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_1_60' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_59\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\"><label class='gfield_label gform-field-label' for='input_1_59' >Zo ja: Reinier de Graaf Gasthuis patientnummer<\/label><div class='ginput_container ginput_container_number'><input name='input_59' id='input_1_59' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_30\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><h2 class=\"gsection_title\">Gegevens partner<\/h2><\/li><li id=\"field_1_31\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_1_31'>\n                            \n                            <span id='input_1_31_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_31.3' id='input_1_31_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_31_3' class='gform-field-label gform-field-label--type-sub'>Roepnaam<\/label>\n                                                <\/span>\n                            <span id='input_1_31_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_31.4' id='input_1_31_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_31_4' class='gform-field-label gform-field-label--type-sub'>Preposition<\/label>\n                                                <\/span>\n                            <span id='input_1_31_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_31.6' id='input_1_31_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_31_6' class='gform-field-label gform-field-label--type-sub'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_32\"  class=\"gfield gfield--type-date gfield--input-type-datedropdown field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\"><label class='gfield_label gform-field-label'  >Date of birth<\/label><div id='input_1_32' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_1_32_2_container'><select name='input_32[]' id='input_1_32_2'   aria-required='false'  ><option value=''>Dag<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_1_32_1_container'><select name='input_32[]' id='input_1_32_1'   aria-required='false'  ><option value=''>Maand<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_1_32_3_container'><select name='input_32[]' id='input_1_32_3'   aria-required='false'  ><option value=''>Jaar<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_1_33\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\"><label class='gfield_label gform-field-label' for='input_1_33' >Mobile number<\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_1_33' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_34\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\"><label class='gfield_label gform-field-label' for='input_1_34' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_34' id='input_1_34' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_38\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\"><label class='gfield_label gform-field-label' for='input_1_38' >Beroep<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_37\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\"><label class='gfield_label gform-field-label' for='input_1_37' >Beroep status<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_1_37' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Full-time baan' >Full-time baan<\/option><option value='Part-time baan' >Part-time baan<\/option><option value='Werkzoekend' >Werkzoekend<\/option><option value='WAO' >WAO<\/option><option value='Niet werken, vrije keus' >Niet werken, vrije keus<\/option><option value='Onbekend' >Onbekend<\/option><\/select><\/div><\/li><li id=\"field_1_40\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_40\"><label class='gfield_label gform-field-label' for='input_1_40' >Opleiding<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Geen opleiding' >Geen opleiding<\/option><option value='Lager algemeen onderwijs' >Lager algemeen onderwijs<\/option><option value='Lager beroepsonderwijs (LBO)' >Lager beroepsonderwijs (LBO)<\/option><option value='Middelbaar algemeen onderwijs (MAVO\/VMBO)' >Middelbaar algemeen onderwijs (MAVO\/VMBO)<\/option><option value='Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)' >Middelbaar beroepsonderwijs (MBO inc. MEAO en MTS)<\/option><option value='Hoger algemeen onderwijs (HAVO\/VWO)' >Hoger algemeen onderwijs (HAVO\/VWO)<\/option><option value='Hoger beroepsonderwijs (HBO, inc HEAO en HTS)' >Hoger beroepsonderwijs (HBO, inc HEAO en HTS)<\/option><option value='Wetenschappelijk onderwijs (Universiteit\/hogeschool)' >Wetenschappelijk onderwijs (Universiteit\/hogeschool)<\/option><option value='Overig onderwijs' >Overig onderwijs<\/option><\/select><\/div><\/li><li id=\"field_1_18\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\"><label class='gfield_label gform-field-label' for='input_1_18' >Heeft uw partner kinderen uit een eerdere relatie?<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_1_18' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_22\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\"><h2 class=\"gsection_title\">Gegevens zwangerschap<\/h2><\/li><li id=\"field_1_12\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\"><label class='gfield_label gform-field-label' for='input_1_12' >Wanneer was de eerste dag van uw laatste menstruatie?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_1_12' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='25\/04\/2026' aria-describedby=\"input_1_12_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_12_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_12' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_52\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_52\"><label class='gfield_label gform-field-label' for='input_1_52' >Wat is de duur van je cyclus?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_52\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_52'>Dagen<\/div><\/li><li id=\"field_1_51\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\"><label class='gfield_label gform-field-label' for='input_1_51' >Heeft u anticonceptie gebruikt voor de zwangerschap?<\/label><div class='ginput_container ginput_container_select'><select name='input_51' id='input_1_51' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Ja' >Ja<\/option><option value='Nee' >Nee<\/option><\/select><\/div><\/li><li id=\"field_1_54\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\"><label class='gfield_label gform-field-label' for='input_1_54' >Zo ja, welke soort?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_54\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_54'>Contraception<\/div><\/li><li id=\"field_1_70\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\"><label class='gfield_label gform-field-label' for='input_1_70' >Hoeveel maanden heeft u kinderwens?<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_55\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\"><label class='gfield_label gform-field-label' for='input_1_55' >Datum 1e zwangerschapstest<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_55' id='input_1_55' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_1_55_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_55_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_55' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_53\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\"><label class='gfield_label gform-field-label' for='input_1_53' >1e zwangerschapstest<\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_1_53' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Positief' >Positief<\/option><option value='Negatief' >Negatief<\/option><\/select><\/div><\/li><li id=\"field_1_56\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\"><label class='gfield_label gform-field-label' for='input_1_56' >Datum 2e zwangerschapstest<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_56' id='input_1_56' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_1_56_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_56_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_56' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_1_58\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\"><label class='gfield_label gform-field-label' for='input_1_58' >2e zwangerschapstest<\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_1_58' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Positief' >Positief<\/option><option value='Negatief' >Negatief<\/option><\/select><\/div><\/li><li id=\"field_1_61\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\"><label class='gfield_label gform-field-label' for='input_1_61' >Heeft u een fertiliteits behandeling gehad?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_61' id='input_1_61' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_72\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\"><label class='gfield_label gform-field-label' for='input_1_72' >Zo ja, welke?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_1_13\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\"><label class='gfield_label gform-field-label'  >Hoeveelste zwangerschap is dit voor u?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_13'>\n\t\t\t<li class='gchoice gchoice_1_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Eerste zwangerschap'  id='choice_1_13_0'    \/>\n\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Eerste zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Tweede zwangerschap'  id='choice_1_13_1'    \/>\n\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Tweede zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_2'>\n\t\t\t\t<input name='input_13' type='radio' value='Derde zwangerschap'  id='choice_1_13_2'    \/>\n\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>Derde zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_3'>\n\t\t\t\t<input name='input_13' type='radio' value='Vierde zwangerschap'  id='choice_1_13_3'    \/>\n\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Vierde zwangerschap<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_13_4'>\n\t\t\t\t<input name='input_13' type='radio' value='Vijfde of volgende zwangerschap'  id='choice_1_13_4'    \/>\n\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>Vijfde of volgende zwangerschap<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_57\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\"><label class='gfield_label gform-field-label' for='input_1_57' >Hebt u ooit een miskraam of abortus gehad?<\/label><div class='ginput_container ginput_container_select'><select name='input_57' id='input_1_57' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_19\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_label gform-field-label' for='input_1_19' >Is er in DEZE zwangerschap een echo gemaakt?<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_20\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_label gform-field-label' for='input_1_20' >Komen er aangeboren of erfelijke afwijkingen voor in uw familie of in de familie van uw partner?<\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Nee' >Nee<\/option><option value='Ja' >Ja<\/option><\/select><\/div><\/li><li id=\"field_1_43\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><label class='gfield_label gform-field-label' for='input_1_43' >Zo ja, graag toelichten<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_1_43' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_44\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\"><label class='gfield_label gform-field-label'  >Moeders voor Moeders<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_44'>\n\t\t\t<li class='gchoice gchoice_1_44_0'>\n\t\t\t\t<input name='input_44' type='radio' value='Ik geef toestemming om mijn telefoonnummer door te geven aan de consulente'  id='choice_1_44_0'    \/>\n\t\t\t\t<label for='choice_1_44_0' id='label_1_44_0' class='gform-field-label gform-field-label--type-inline'>Ik geef toestemming om mijn telefoonnummer door te geven aan de consulente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_44_1'>\n\t\t\t\t<input name='input_44' type='radio' value='Ik geef GEEN toestemming om mijn telefoonnummer door te geven aan de consulente'  id='choice_1_44_1'    \/>\n\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Ik geef GEEN toestemming om mijn telefoonnummer door te geven aan de consulente<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_44'>Wij ondersteunen Moeders voor Moeders, een organisatie die de kinderwens van stellen met vruchtbaarheidsproblemen vervullen. Wij willen graag uw telefoonnummer doorgeven aan de consulente van moeders voor moeders, die vrijblijvend contact met u opneemt om u hier verder over te informeren. \nwww.moedersvoormoeders.nl <\/div><\/li><li id=\"field_1_45\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\"><label class='gfield_label gform-field-label'  >Email updates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_45'>\n\t\t\t<li class='gchoice gchoice_1_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Ik wil graag informatie via email ontvangen van DelVi'  id='choice_1_45_0'    \/>\n\t\t\t\t<label for='choice_1_45_0' id='label_1_45_0' class='gform-field-label gform-field-label--type-inline'>Ik wil graag informatie via email ontvangen van DelVi<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='Ik wens GEEN informatie via email te ontvangen van DelVi'  id='choice_1_45_1'    \/>\n\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>Ik wens GEEN informatie via email te ontvangen van DelVi<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_45'>Tijdens uw zwangerschap willen wij graag extra informatie via email versturen. Deze informatie dient als aanvulling op onze zorg. \n* Let op! Wij zullen uw gegevens NOOIT delen met derde partijen. <\/div><\/li><li id=\"field_1_46\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\"><label class='gfield_label gform-field-label'  >Email updates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_46'>\n\t\t\t<li class='gchoice gchoice_1_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Mijn partner wil graag extra informatie via email ontvangen van DelVi'  id='choice_1_46_0'    \/>\n\t\t\t\t<label for='choice_1_46_0' id='label_1_46_0' class='gform-field-label gform-field-label--type-inline'>Mijn partner wil graag extra informatie via email ontvangen van DelVi<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='Mijn partner wenst GEEN extra informatie via email te ontvangen van DelVi'  id='choice_1_46_1'    \/>\n\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>Mijn partner wenst GEEN extra informatie via email te ontvangen van DelVi<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_46_2'>\n\t\t\t\t<input name='input_46' type='radio' value='NVT'  id='choice_1_46_2'    \/>\n\t\t\t\t<label for='choice_1_46_2' id='label_1_46_2' class='gform-field-label gform-field-label--type-inline'>NVT<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_1_46'>Uw partner kan er ook voor kiezen om deze extra informatie via email te ontvangen. \n* Let op! Wij zullen uw gegevens NOOIT delen met derde partijen. <\/div><\/li><li id=\"field_1_21\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\"><label class='gfield_label gform-field-label' for='input_1_21' >Eventuele bijzonderheden\/mededelingen\/vragen<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_1_21' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_73\"  class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_73\"><label class='gfield_label gform-field-label' for='input_1_73' >Email<\/label><div class='ginput_container'><input name='input_73' id='input_1_73' type='text' value='' \/><\/div><div class='gfield_description' id='gfield_description_1_73'>This field is for validation purposes and should be left unchanged.<\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Versturen'  onclick='if(window[\"gf_submitting_1\"]){return false;}  window[\"gf_submitting_1\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} window[\"gf_submitting_1\"]=true;  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsImIzODJiMzc5YmUzYTJjN2I1YWZlYWRjZTM1NTdjYWRiIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n                        <\/div><script type=\"text\/javascript\">\ngform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}, 50);}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [1, current_page]);gform.utils.trigger({ event: 'gform\/postRender', native: false, data: { formId: 1, currentPage: current_page } });} );} );\n<\/script>\n \n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='1' id='gform_wrapper_2' >\n                        <div class='gform_heading'>\n                            <h3 class=\"gform_title\">Form 1. Registration<\/h3>\n                            <p class='gform_description'>You can register with us online by filling in this registration form. Once we have received your registration our assistant will contact you within 3 working days to schedule an appointment.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/377' data-formid='2' data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/377\" >\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_1\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\"><h2 class=\"gsection_title\">Personal details<\/h2><\/li><li id=\"field_2_2\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_2'>\n                            \n                            <span id='input_2_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_2_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_7\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_7\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Initials<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_2_7'>\n                            \n                            <span id='input_2_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_2_7_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_7_3' class='gform-field-label gform-field-label--type-sub'>Initials<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_2_61\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_61\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Maiden name (if applicable)<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_2_61'>\n                            \n                            \n                            \n                            <span id='input_2_61_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_61.6' id='input_2_61_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_61_6' class='gform-field-label gform-field-label--type-sub'>Maiden name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_3\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_2_3' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_2_3_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_3_1' id='input_2_3_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_3' id='input_2_3_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_3.4' id='input_2_3_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_2_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_2_3_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_3_5' id='input_2_3_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_2_3_6_container' >\n                                        <select name='input_3.6' id='input_2_3_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' selected='selected'>Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_3_6' id='input_2_3_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_4\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_4\"><label class='gfield_label gform-field-label' for='input_2_4' >Telephone number<\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_42\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_42\"><label class='gfield_label gform-field-label' for='input_2_42' >Mobile number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_2_42' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_6\"  class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_6\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_2_6' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_6_2_container'>\n                                            <input type='text' maxlength='2' name='input_6[]' id='input_2_6_2' value=''   aria-required='true'   placeholder='DD' \/>\n                                            <label for='input_2_6_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_6_1_container'>\n                                        <input type='text' maxlength='2' name='input_6[]' id='input_2_6_1' value=''   aria-required='true'   placeholder='MM' \/>\n                                        <label for='input_2_6_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_6_3_container'>\n                                        <input type='text' maxlength='4' name='input_6[]' id='input_2_6_3' value=''   aria-required='true'   placeholder='YYYY'   \/>\n                                        <label for='input_2_6_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_2_5\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\"><label class='gfield_label gform-field-label' for='input_2_5' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_16\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\"><label class='gfield_label gform-field-label' for='input_2_16' >Burgerservicenummer (BSN)<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_8\"  class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_8\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Country of birth<\/label>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_2_8' >\n                        <input type='hidden' class='gform_hidden' name='input_8.4' id='input_2_8_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_2_8_6_container' >\n                                        <select name='input_8.6' id='input_2_8_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_2_8_6' id='input_2_8_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_2_44\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_44\"><label class='gfield_label gform-field-label' for='input_2_44' >Nationality<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_2_44' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_45\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_45\"><label class='gfield_label gform-field-label' for='input_2_45' >Ethnicity<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_62\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_62\"><label class='gfield_label gform-field-label'  >Marital status<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_62'>\n\t\t\t<li class='gchoice gchoice_2_62_0'>\n\t\t\t\t<input name='input_62' type='radio' value='Married'  id='choice_2_62_0'    \/>\n\t\t\t\t<label for='choice_2_62_0' id='label_2_62_0' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_1'>\n\t\t\t\t<input name='input_62' type='radio' value='Living together'  id='choice_2_62_1'    \/>\n\t\t\t\t<label for='choice_2_62_1' id='label_2_62_1' class='gform-field-label gform-field-label--type-inline'>Living together<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_2'>\n\t\t\t\t<input name='input_62' type='radio' value='Registered partnership'  id='choice_2_62_2'    \/>\n\t\t\t\t<label for='choice_2_62_2' id='label_2_62_2' class='gform-field-label gform-field-label--type-inline'>Registered partnership<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_3'>\n\t\t\t\t<input name='input_62' type='radio' value='Single'  id='choice_2_62_3'    \/>\n\t\t\t\t<label for='choice_2_62_3' id='label_2_62_3' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_4'>\n\t\t\t\t<input name='input_62' type='radio' value='Divorced'  id='choice_2_62_4'    \/>\n\t\t\t\t<label for='choice_2_62_4' id='label_2_62_4' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_62_5'>\n\t\t\t\t<input name='input_62' type='radio' value='gf_other_choice'  id='choice_2_62_5'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_62_other' name='input_62_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_63\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_63\"><label class='gfield_label gform-field-label'  >Religion<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_63'>\n\t\t\t<li class='gchoice gchoice_2_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='None'  id='choice_2_63_0'    \/>\n\t\t\t\t<label for='choice_2_63_0' id='label_2_63_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='Roman Catholic'  id='choice_2_63_1'    \/>\n\t\t\t\t<label for='choice_2_63_1' id='label_2_63_1' class='gform-field-label gform-field-label--type-inline'>Roman Catholic<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_2'>\n\t\t\t\t<input name='input_63' type='radio' value='Christian'  id='choice_2_63_2'    \/>\n\t\t\t\t<label for='choice_2_63_2' id='label_2_63_2' class='gform-field-label gform-field-label--type-inline'>Christian<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_3'>\n\t\t\t\t<input name='input_63' type='radio' value='Jehovah&#039;s witness'  id='choice_2_63_3'    \/>\n\t\t\t\t<label for='choice_2_63_3' id='label_2_63_3' class='gform-field-label gform-field-label--type-inline'>Jehovah's witness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_4'>\n\t\t\t\t<input name='input_63' type='radio' value='Islam'  id='choice_2_63_4'    \/>\n\t\t\t\t<label for='choice_2_63_4' id='label_2_63_4' class='gform-field-label gform-field-label--type-inline'>Islam<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_5'>\n\t\t\t\t<input name='input_63' type='radio' value='Hindu'  id='choice_2_63_5'    \/>\n\t\t\t\t<label for='choice_2_63_5' id='label_2_63_5' class='gform-field-label gform-field-label--type-inline'>Hindu<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_6'>\n\t\t\t\t<input name='input_63' type='radio' value='Protestant'  id='choice_2_63_6'    \/>\n\t\t\t\t<label for='choice_2_63_6' id='label_2_63_6' class='gform-field-label gform-field-label--type-inline'>Protestant<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_63_7'>\n\t\t\t\t<input name='input_63' type='radio' value='gf_other_choice'  id='choice_2_63_7'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_63_other' name='input_63_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_12\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\"><label class='gfield_label gform-field-label' for='input_2_12' >Employment status<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_12[]' id='input_2_12' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Employed Full-Time' >Employed Full-Time<\/option><option value='Employed Part-Time' >Employed Part-Time<\/option><option value='Self-employed' >Self-employed<\/option><option value='Not employed but looking for work' >Not employed but looking for work<\/option><option value='Not employed and not looking for work' >Not employed and not looking for work<\/option><option value='Homemaker' >Homemaker<\/option><option value='Retired' >Retired<\/option><option value='Student' >Student<\/option><option value='Prefer Not to Answer' >Prefer Not to Answer<\/option><\/select><\/div><\/li><li id=\"field_2_13\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\"><label class='gfield_label gform-field-label' for='input_2_13' >Profession<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_13[]' id='input_2_13' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Accounting\/Finance' >Accounting\/Finance<\/option><option value='Advertising\/Public Relations' >Advertising\/Public Relations<\/option><option value='Aerospace\/Aviation' >Aerospace\/Aviation<\/option><option value='Arts\/Entertainment\/Publishing' >Arts\/Entertainment\/Publishing<\/option><option value='Automotive' >Automotive<\/option><option value='Banking\/Mortgage' >Banking\/Mortgage<\/option><option value='Business Development' >Business Development<\/option><option value='Business Opportunity' >Business Opportunity<\/option><option value='Clerical\/Administrative' >Clerical\/Administrative<\/option><option value='Construction\/Facilities' >Construction\/Facilities<\/option><option value='Consumer Goods' >Consumer Goods<\/option><option value='Customer Service' >Customer Service<\/option><option value='Education\/Training' >Education\/Training<\/option><option value='Energy\/Utilities' >Energy\/Utilities<\/option><option value='Engineering' >Engineering<\/option><option value='Government\/Military' >Government\/Military<\/option><option value='Green' >Green<\/option><option value='Healthcare' >Healthcare<\/option><option value='Hospitality\/Travel' >Hospitality\/Travel<\/option><option value='Human Resources' >Human Resources<\/option><option value='Installation\/Maintenance' >Installation\/Maintenance<\/option><option value='Insurance' >Insurance<\/option><option value='Internet' >Internet<\/option><option value='Job Search Aids' >Job Search Aids<\/option><option value='Law Enforcement\/Security' >Law Enforcement\/Security<\/option><option value='Legal' >Legal<\/option><option value='Management\/Executive' >Management\/Executive<\/option><option value='Manufacturing\/Operations' >Manufacturing\/Operations<\/option><option value='Marketing' >Marketing<\/option><option value='Non-Profit\/Volunteer' >Non-Profit\/Volunteer<\/option><option value='Pharmaceutical\/Biotech' >Pharmaceutical\/Biotech<\/option><option value='Professional Services' >Professional Services<\/option><option value='QA\/Quality Control' >QA\/Quality Control<\/option><option value='Real Estate' >Real Estate<\/option><option value='Restaurant\/Food Service' >Restaurant\/Food Service<\/option><option value='Retail' >Retail<\/option><option value='Sales' >Sales<\/option><option value='Science\/Research' >Science\/Research<\/option><option value='Skilled Labor' >Skilled Labor<\/option><option value='Technology' >Technology<\/option><option value='Telecommunications' >Telecommunications<\/option><option value='Transportation\/Logistics' >Transportation\/Logistics<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_14\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\"><label class='gfield_label gform-field-label' for='input_2_14' >Education<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_14[]' id='input_2_14' class='medium gfield_select'   aria-invalid=\"false\"  aria-describedby=\"gfield_description_2_14\"><option value='High School' >High School<\/option><option value='College' >College<\/option><option value='Bachelor&#039;s Degree' >Bachelor&#039;s Degree<\/option><option value='Masters' >Masters<\/option><option value='PhD' >PhD<\/option><option value='Other' >Other<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_14'>Highest level of qualification achieved<\/div><\/li><li id=\"field_2_43\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_43\"><label class='gfield_label gform-field-label' for='input_2_43' >If not, which language(s) do you speak?<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_2_43' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_15\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\"><label class='gfield_label gform-field-label' for='input_2_15' >Do you speak Dutch?<\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_2_15' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='A little' >A little<\/option><\/select><\/div><\/li><li id=\"field_2_17\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\"><label class='gfield_label gform-field-label' for='input_2_17' >Height (cm)<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_18\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_18\"><label class='gfield_label gform-field-label' for='input_2_18' >Weight (kg)<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_19\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_19\"><label class='gfield_label gform-field-label' for='input_2_19' >Have you been a client in our practice previously?<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_2_19' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_2_20\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_20\"><label class='gfield_label gform-field-label' for='input_2_20' >Who is your GP? (Family doctor)<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_46\"  class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_46\"><label class='gfield_label gform-field-label' for='input_2_46' >Which chemist are you registered with?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='medium'  aria-describedby=\"gfield_description_2_46\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_2_46'>Apotheek<\/div><\/li><li id=\"field_2_21\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_21\"><label class='gfield_label gform-field-label' for='input_2_21' >Health insurance company<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_2_21' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_22\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_22\"><label class='gfield_label gform-field-label' for='input_2_22' >Health insurance policy number<\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_2_22' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_2_48\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_48\"><label class='gfield_label gform-field-label'  >Are you registered with the Reinier de Graaf hospital?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_48'>\n\t\t\t<li class='gchoice gchoice_2_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Yes'  id='choice_2_48_0'    \/>\n\t\t\t\t<label for='choice_2_48_0' id='label_2_48_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='No'  id='choice_2_48_1'    \/>\n\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_47\"  class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_47\"><label class='gfield_label gform-field-label' for='input_2_47' >If yes, what is your Reinier de Graaf patient number?<\/label><div class='ginput_container ginput_container_number'><input name='input_47' id='input_2_47' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_2_23\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_23\"><h2 class=\"gsection_title\">Partner&#039;s details<\/h2><\/li><li id=\"field_2_24\"  class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_24\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_24'>\n                            \n                            <span id='input_2_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_2_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_2_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_2_24_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_2_25\"  class=\"gfield gfield--type-date gfield--input-type-datefield field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_25\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Date of birth<\/label><div id='input_2_25' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_2_25_2_container'>\n                                            <input type='text' maxlength='2' name='input_25[]' id='input_2_25_2' value=''   aria-required='false'   placeholder='DD' \/>\n                                            <label for='input_2_25_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_2_25_1_container'>\n                                        <input type='text' maxlength='2' name='input_25[]' id='input_2_25_1' value=''   aria-required='false'   placeholder='MM' \/>\n                                        <label for='input_2_25_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_2_25_3_container'>\n                                        <input type='text' maxlength='4' name='input_25[]' id='input_2_25_3' value=''   aria-required='false'   placeholder='YYYY'   \/>\n                                        <label for='input_2_25_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_2_26\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_26\"><label class='gfield_label gform-field-label' for='input_2_26' >Telephone number<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_2_26' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_27\"  class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_27\"><label class='gfield_label gform-field-label' for='input_2_27' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_27' id='input_2_27' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_28\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_28\"><label class='gfield_label gform-field-label' for='input_2_28' >Profession<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_28[]' id='input_2_28' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Accounting\/Finance' >Accounting\/Finance<\/option><option value='Advertising\/Public Relations' >Advertising\/Public Relations<\/option><option value='Aerospace\/Aviation' >Aerospace\/Aviation<\/option><option value='Arts\/Entertainment\/Publishing' >Arts\/Entertainment\/Publishing<\/option><option value='Automotive' >Automotive<\/option><option value='Banking\/Mortgage' >Banking\/Mortgage<\/option><option value='Business Development' >Business Development<\/option><option value='Business Opportunity' >Business Opportunity<\/option><option value='Clerical\/Administrative' >Clerical\/Administrative<\/option><option value='Construction\/Facilities' >Construction\/Facilities<\/option><option value='Consumer Goods' >Consumer Goods<\/option><option value='Customer Service' >Customer Service<\/option><option value='Education\/Training' >Education\/Training<\/option><option value='Energy\/Utilities' >Energy\/Utilities<\/option><option value='Engineering' >Engineering<\/option><option value='Government\/Military' >Government\/Military<\/option><option value='Green' >Green<\/option><option value='Healthcare' >Healthcare<\/option><option value='Hospitality\/Travel' >Hospitality\/Travel<\/option><option value='Human Resources' >Human Resources<\/option><option value='Installation\/Maintenance' >Installation\/Maintenance<\/option><option value='Insurance' >Insurance<\/option><option value='Internet' >Internet<\/option><option value='Job Search Aids' >Job Search Aids<\/option><option value='Law Enforcement\/Security' >Law Enforcement\/Security<\/option><option value='Legal' >Legal<\/option><option value='Management\/Executive' >Management\/Executive<\/option><option value='Manufacturing\/Operations' >Manufacturing\/Operations<\/option><option value='Marketing' >Marketing<\/option><option value='Non-Profit\/Volunteer' >Non-Profit\/Volunteer<\/option><option value='Pharmaceutical\/Biotech' >Pharmaceutical\/Biotech<\/option><option value='Professional Services' >Professional Services<\/option><option value='QA\/Quality Control' >QA\/Quality Control<\/option><option value='Real Estate' >Real Estate<\/option><option value='Restaurant\/Food Service' >Restaurant\/Food Service<\/option><option value='Retail' >Retail<\/option><option value='Sales' >Sales<\/option><option value='Science\/Research' >Science\/Research<\/option><option value='Skilled Labor' >Skilled Labor<\/option><option value='Technology' >Technology<\/option><option value='Telecommunications' >Telecommunications<\/option><option value='Transportation\/Logistics' >Transportation\/Logistics<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_2_29\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_29\"><label class='gfield_label gform-field-label' for='input_2_29' >Employment status<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_29[]' id='input_2_29' class='medium gfield_select'   aria-invalid=\"false\"  ><option value='Employed Full-Time' >Employed Full-Time<\/option><option value='Employed Part-Time' >Employed Part-Time<\/option><option value='Self-employed' >Self-employed<\/option><option value='Not employed but looking for work' >Not employed but looking for work<\/option><option value='Not employed and not looking for work' >Not employed and not looking for work<\/option><option value='Homemaker' >Homemaker<\/option><option value='Retired' >Retired<\/option><option value='Student' >Student<\/option><option value='Prefer Not to Answer' >Prefer Not to Answer<\/option><\/select><\/div><\/li><li id=\"field_2_49\"  class=\"gfield gfield--type-multiselect field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_49\"><label class='gfield_label gform-field-label' for='input_2_49' >Education<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_49[]' id='input_2_49' class='medium gfield_select'   aria-invalid=\"false\"  aria-describedby=\"gfield_description_2_49\"><option value='High School' >High School<\/option><option value='College' >College<\/option><option value='Bachelor&#039;s Degree' >Bachelor&#039;s Degree<\/option><option value='Masters' >Masters<\/option><option value='PhD' >PhD<\/option><option value='Other' >Other<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_2_49'>Highest level of qualification achieved<\/div><\/li><li id=\"field_2_50\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_50\"><label class='gfield_label gform-field-label'  >Does your partner have children from a previous relationship?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_50'>\n\t\t\t<li class='gchoice gchoice_2_50_0'>\n\t\t\t\t<input name='input_50' type='radio' value='No'  id='choice_2_50_0'    \/>\n\t\t\t\t<label for='choice_2_50_0' id='label_2_50_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_50_1'>\n\t\t\t\t<input name='input_50' type='radio' value='Yes'  id='choice_2_50_1'    \/>\n\t\t\t\t<label for='choice_2_50_1' id='label_2_50_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_30\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_30\"><h2 class=\"gsection_title\">Pregnancy details<\/h2><\/li><li id=\"field_2_31\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_31\"><label class='gfield_label gform-field-label' for='input_2_31' >When was the first day of your last period?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_31' id='input_2_31' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_2_31_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_31_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_31' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_51\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_51\"><label class='gfield_label gform-field-label' for='input_2_51' >How long is your cycle?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_51' id='input_2_51' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_2_51_date_format gfield_description_2_51\" aria-invalid=\"false\" \/>\n                            <span id='input_2_51_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_51' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_2_51'>number of days between periods (eg. 28) <\/div><\/li><li id=\"field_2_53\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_53\"><label class='gfield_label gform-field-label'  >Were you using contraception before your pregnancy?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_53'>\n\t\t\t<li class='gchoice gchoice_2_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='Yes'  id='choice_2_53_0'    \/>\n\t\t\t\t<label for='choice_2_53_0' id='label_2_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_2_53_1'    \/>\n\t\t\t\t<label for='choice_2_53_1' id='label_2_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_64\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_64\"><label class='gfield_label gform-field-label' for='input_2_64' >If yes, what type of contraception were you using?<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_2_64' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_56\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_56\"><label class='gfield_label gform-field-label' for='input_2_56' >Date of first pregnancy test<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_56' id='input_2_56' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_2_56_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_56_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_56' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_32\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_32\"><label class='gfield_label gform-field-label'  >Result<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_32'>\n\t\t\t<li class='gchoice gchoice_2_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Positive'  id='choice_2_32_0'    \/>\n\t\t\t\t<label for='choice_2_32_0' id='label_2_32_0' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Negative'  id='choice_2_32_1'    \/>\n\t\t\t\t<label for='choice_2_32_1' id='label_2_32_1' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_55\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_55\"><label class='gfield_label gform-field-label' for='input_2_55' >Date of second pregnancy test<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_55' id='input_2_55' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_2_55_date_format gfield_description_2_55\" aria-invalid=\"false\" \/>\n                            <span id='input_2_55_date_format' class='screen-reader-text'>DD dash MM dash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_55' class='gform_hidden' value='https:\/\/delvi.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_2_55'>if you have done one<\/div><\/li><li id=\"field_2_58\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_58\"><label class='gfield_label gform-field-label'  >Result<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_58'>\n\t\t\t<li class='gchoice gchoice_2_58_0'>\n\t\t\t\t<input name='input_58' type='radio' value='Positive'  id='choice_2_58_0'    \/>\n\t\t\t\t<label for='choice_2_58_0' id='label_2_58_0' class='gform-field-label gform-field-label--type-inline'>Positive<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_58_1'>\n\t\t\t\t<input name='input_58' type='radio' value='Negative'  id='choice_2_58_1'    \/>\n\t\t\t\t<label for='choice_2_58_1' id='label_2_58_1' class='gform-field-label gform-field-label--type-inline'>Negative<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_59\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_59\"><label class='gfield_label gform-field-label'  >Have you received any form of fertility treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_59'>\n\t\t\t<li class='gchoice gchoice_2_59_0'>\n\t\t\t\t<input name='input_59' type='radio' value='No'  id='choice_2_59_0'    \/>\n\t\t\t\t<label for='choice_2_59_0' id='label_2_59_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_59_1'>\n\t\t\t\t<input name='input_59' type='radio' value='Yes'  id='choice_2_59_1'    \/>\n\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_36\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_36\"><label class='gfield_label gform-field-label' for='input_2_36' >If yes, please tell us more about this treatment?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_2_36' class='textarea medium'  aria-describedby=\"gfield_description_2_36\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_2_36'>treatment type, dates and health care provider <\/div><\/li><li id=\"field_2_57\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_57\"><label class='gfield_label gform-field-label'  >What number pregnancy is this for you?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_57'>\n\t\t\t<li class='gchoice gchoice_2_57_0'>\n\t\t\t\t<input name='input_57' type='radio' value='First pregnancy'  id='choice_2_57_0'    \/>\n\t\t\t\t<label for='choice_2_57_0' id='label_2_57_0' class='gform-field-label gform-field-label--type-inline'>First pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_1'>\n\t\t\t\t<input name='input_57' type='radio' value='Second pregnancy'  id='choice_2_57_1'    \/>\n\t\t\t\t<label for='choice_2_57_1' id='label_2_57_1' class='gform-field-label gform-field-label--type-inline'>Second pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_2'>\n\t\t\t\t<input name='input_57' type='radio' value='Third pregnancy'  id='choice_2_57_2'    \/>\n\t\t\t\t<label for='choice_2_57_2' id='label_2_57_2' class='gform-field-label gform-field-label--type-inline'>Third pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_3'>\n\t\t\t\t<input name='input_57' type='radio' value='Fourth pregnancy'  id='choice_2_57_3'    \/>\n\t\t\t\t<label for='choice_2_57_3' id='label_2_57_3' class='gform-field-label gform-field-label--type-inline'>Fourth pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_57_4'>\n\t\t\t\t<input name='input_57' type='radio' value='Fifth or subsequent pregnancy'  id='choice_2_57_4'    \/>\n\t\t\t\t<label for='choice_2_57_4' id='label_2_57_4' class='gform-field-label gform-field-label--type-inline'>Fifth or subsequent pregnancy<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_52\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_52\"><label class='gfield_label gform-field-label' for='input_2_52' >Have you ever had a miscarriage or termination?<\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_2_52' class='medium gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_2_34\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_34\"><label class='gfield_label gform-field-label' for='input_2_34' >Have you had an ultrasound scan in THIS pregnancy?<\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_2_34' class='medium gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_2_35\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_35\"><label class='gfield_label gform-field-label' for='input_2_35' >Is there a history of hereditary disease(s) in your family, or your partner&#039;s family?<\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_2_35' class='medium gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_2_37\"  class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_37\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Moeders voor Moeders<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_37'><li class='gchoice gchoice_2_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='I would prefer NOT to have my telephone number passed on to Moeders voor Moeders'  id='choice_2_37_1'   aria-describedby=\"gfield_description_2_37\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_37_1' id='label_2_37_1' class='gform-field-label gform-field-label--type-inline'>I would prefer NOT to have my telephone number passed on to Moeders voor Moeders<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_37'>We actively support the Mother's for Mother's initiative that helps women with fertility issues to be able to get pregnant. To this end we would like to pass on your telephone number to the local representative who will contact you to give you further information about this initiative (with no obligation).  We encourage you to consider helping this worthy cause, however, if you prefer not to be contacted, please check the box. \nwww.moedersvoormoeders.nl <\/div><\/li><li id=\"field_2_39\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_39\"><label class='gfield_label gform-field-label'  >Email updates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_39'>\n\t\t\t<li class='gchoice gchoice_2_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='I agree to receiving information via email from DelVi during my pregnancy'  id='choice_2_39_0'    \/>\n\t\t\t\t<label for='choice_2_39_0' id='label_2_39_0' class='gform-field-label gform-field-label--type-inline'>I agree to receiving information via email from DelVi during my pregnancy<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='I do not wish to receive information via email from DelVi during my pregnancy'  id='choice_2_39_1'    \/>\n\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1' class='gform-field-label gform-field-label--type-inline'>I do not wish to receive information via email from DelVi during my pregnancy<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_2_39'>We will send you email updates with relevant information during your pregnancy as part of the care you receive in our midwifery centre. \n*Please note - this information is purely to support our care and we will never pass your details on to third parties. <\/div><\/li><li id=\"field_2_60\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_60\"><label class='gfield_label gform-field-label' for='input_2_60' >If yes, please tell us more information<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_2_60' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_41\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_41\"><label class='gfield_label gform-field-label'  >Email updates partner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_41'>\n\t\t\t<li class='gchoice gchoice_2_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='My partner wishes to receive email updates from DelVi 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