{"id":2220,"date":"2024-12-11T15:13:03","date_gmt":"2024-12-11T14:13:03","guid":{"rendered":"https:\/\/fonkelzorginternational.nl\/suscribete\/"},"modified":"2025-01-28T22:27:55","modified_gmt":"2025-01-28T21:27:55","slug":"suscribete","status":"publish","type":"page","link":"https:\/\/fonkelzorginternational.nl\/es\/suscribete\/","title":{"rendered":"Reg\u00edstrate"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00bb1&#8243; _builder_version=\u00bb4.27.2&#8243; _module_preset=\u00bbdefault\u00bb background_color=\u00bb#f4f7f7&#8243; global_colors_info=\u00bb{}\u00bb][et_pb_row column_structure=\u00bb1_2,1_2&#8243; _builder_version=\u00bb4.27.2&#8243; _module_preset=\u00bba46ce895-6748-4abb-8161-ec4d10458851&#8243; global_colors_info=\u00bb{}\u00bb][et_pb_column type=\u00bb1_2&#8243; _builder_version=\u00bb4.27.2&#8243; _module_preset=\u00bbdefault\u00bb background_image=\u00bbhttps:\/\/fonkelzorginternational.nl\/wp-content\/uploads\/2024\/12\/yellow-border-hexa.svg\u00bb background_size=\u00bbcontain\u00bb global_colors_info=\u00bb{}\u00bb][et_pb_image src=\u00bbhttps:\/\/fonkelzorginternational.nl\/wp-content\/uploads\/2025\/01\/doc-img.jpg\u00bb title_text=\u00bbdoc-img\u00bb _builder_version=\u00bb4.27.4&#8243; _module_preset=\u00bbdefault\u00bb width=\u00bb400px\u00bb width_tablet=\u00bb300px\u00bb width_phone=\u00bb250px\u00bb width_last_edited=\u00bbon|phone\u00bb max_width=\u00bb100%\u00bb height=\u00bb400px\u00bb height_tablet=\u00bb300px\u00bb height_phone=\u00bb250px\u00bb height_last_edited=\u00bbon|phone\u00bb custom_css_main_element=\u00bb clip-path: polygon(50% 0, 100% 25%, 100% 75%, 50% 100%, 0 75%, 0 25%);\u00bb custom_css_free_form=\u00bbselector img {||  object-fit: cover !important;||  width: 100% !important;||}||selector .et_pb_image_wrap {||  width: 100% !important;||}\u00bb global_colors_info=\u00bb{}\u00bb][\/et_pb_image][et_pb_image src=\u00bbhttps:\/\/fonkelzorginternational.nl\/wp-content\/uploads\/2025\/01\/05.-Medium-Medisch-Contact-Centrum-scaled.jpg\u00bb title_text=\u00bb05. Centro de Contacto M\u00e9dico Mediano\u00bb align=\u00bbright\u00bb align_tablet=\u00bbright\u00bb align_phone=\u00bbright\u00bb align_last_edited=\u00bbon|phone\u00bb _builder_version=\u00bb4.27.4&#8243; _module_preset=\u00bbdefault\u00bb width=\u00bb250px\u00bb width_tablet=\u00bb250px\u00bb width_phone=\u00bb180px\u00bb width_last_edited=\u00bbon|phone\u00bb max_width=\u00bb100%\u00bb height=\u00bb250px\u00bb height_tablet=\u00bb250px\u00bb height_phone=\u00bb180px\u00bb height_last_edited=\u00bbon|phone\u00bb custom_margin=\u00bb-150px||||false|false\u00bb custom_margin_tablet=\u00bb-100px||||false|false\u00bb custom_margin_phone=\u00bb-60px||||false|false\u00bb custom_margin_last_edited=\u00bbon|phone\u00bb custom_css_main_element=\u00bb clip-path: polygon(50% 0, 100% 25%, 100% 75%, 50% 100%, 0 75%, 0 25%);\u00bb custom_css_free_form=\u00bbselector img {||  object-fit: cover !important;||  width: 100% !important;||}||selector .et_pb_image_wrap {||  width: 100% !important;||}\u00bb global_colors_info=\u00bb{}\u00bb][\/et_pb_image][et_pb_image src=\u00bbhttps:\/\/fonkelzorginternational.nl\/wp-content\/uploads\/2024\/12\/starts-icon-2nd.svg\u00bb title_text=\u00bbinicio-icono-2&#8243; align=\u00bbright\u00bb _builder_version=\u00bb4.27.2&#8243; _module_preset=\u00bbdefault\u00bb positioning=\u00bbabsolute\u00bb position_origin_a=\u00bbtop_right\u00bb horizontal_offset=\u00bb50px\u00bb z_index=\u00bb15&#8243; width=\u00bb100%\u00bb max_width_tablet=\u00bb80px\u00bb max_width_phone=\u00bb50px\u00bb max_width_last_edited=\u00bbon|tablet\u00bb scroll_vertical_motion_enable=\u00bbon\u00bb scroll_vertical_motion=\u00bb0|50|50|100|-0.5|0|1.5&#8243; locked=\u00bboff\u00bb global_colors_info=\u00bb{}\u00bb][\/et_pb_image][\/et_pb_column][et_pb_column type=\u00bb1_2&#8243; _builder_version=\u00bb4.27.2&#8243; _module_preset=\u00bbdefault\u00bb global_colors_info=\u00bb{}\u00bb][et_pb_text _builder_version=\u00bb4.27.4&#8243; _module_preset=\u00bb2a605431-40b3-4223-9d2e-a62fa9fefc5c\u00bb header_5_font=\u00bb|700||on|||||\u00bb header_5_text_color=\u00bb#8DD0E1&#8243; header_5_line_height=\u00bb20px\u00bb custom_margin=\u00bb||0px||false|false\u00bb locked=\u00bboff\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<h5>Te lo ponemos f\u00e1cil<\/h5>\n<p>[\/et_pb_text][et_pb_text _builder_version=\u00bb4.27.2&#8243; _module_preset=\u00bb2a605431-40b3-4223-9d2e-a62fa9fefc5c\u00bb header_2_font=\u00bb|700|||||||\u00bb header_2_text_color=\u00bb#337D82&#8243; header_2_font_size=\u00bb36px\u00bb header_2_line_height=\u00bb40px\u00bb module_alignment=\u00bbleft\u00bb custom_margin=\u00bb||||false|false\u00bb header_2_font_size_tablet=\u00bb36px\u00bb header_2_font_size_phone=\u00bb\u00bb header_2_font_size_last_edited=\u00bbon|tablet\u00bb locked=\u00bboff\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<h2>Registrarse como paciente<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=\u00bb4.27.4&#8243; _module_preset=\u00bb2a605431-40b3-4223-9d2e-a62fa9fefc5c\u00bb text_text_color=\u00bb#727272&#8243; text_font_size=\u00bb16px\u00bb text_line_height=\u00bb24px\u00bb module_alignment=\u00bbleft\u00bb custom_padding_tablet=\u00bb||0px||false|false\u00bb custom_padding_phone=\u00bb||0px||false|false\u00bb custom_padding_last_edited=\u00bbon|phone\u00bb locked=\u00bboff\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<p>Puedes utilizar este formulario para inscribirte como paciente en Fonkelzorg Internacional. 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inscripci\u00f3n empleados internacionales<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/es\/wp-json\/wp\/v2\/pages\/2220' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_18\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>LinkedIn<\/label><div class='ginput_container'><input name='input_18' id='input_1_18' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_18'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Iniciales<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Apellido<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_1_5' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_1_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_5_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_5' class='gform_hidden' value='https:\/\/fonkelzorginternational.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>G\u00e9nero<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='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Hombre' >Hombre<\/option><option value='Mujer' >Mujer<\/option><option value='Otro \/ no lo dir\u00e1' >Otro \/ no lo dir\u00e1<\/option><\/select><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Direcci\u00f3n en los Pa\u00edses Bajos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>C\u00f3digo postal en los Pa\u00edses Bajos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>N\u00famero de tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Direcci\u00f3n de correo electr\u00f3nico<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_10' id='input_1_10' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>N\u00famero BSN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Aseguradora<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>AON N\u00famero de p\u00f3liza<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Prueba de identidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_1_12' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Pasaporte neerland\u00e9s' >Pasaporte neerland\u00e9s<\/option><option value='DNI holand\u00e9s' >DNI holand\u00e9s<\/option><option value='Documento de extranjer\u00eda' >Documento de extranjer\u00eda<\/option><option value='Pasaporte extranjero' >Pasaporte extranjero<\/option><\/select><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>N\u00famero del documento de identidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Consentimiento del PSL<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_1_14' class='large gfield_select'  aria-describedby=\"gfield_description_1_14\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='S\u00ed' >S\u00ed<\/option><option value='No' >No<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_14'>\u00bfSe puede compartir tu historial m\u00e9dico en caso de urgencia? \u00bfPueden compartirse tus datos m\u00e9dicos en caso de emergencia? Para m\u00e1s informaci\u00f3n, consulta https:\/\/www.volgjezorg.nl\/en<\/div><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >De acuerdo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_15.1' id='input_1_15_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_15_1' >Conozco el descargo de responsabilidad m\u00e9dica para pacientes internacionales y acepto inscribirme como paciente internacional.<\/label><input type='hidden' name='input_15.2' value='Conozco el descargo de responsabilidad m\u00e9dica para pacientes internacionales y acepto inscribirme como paciente internacional.' class='gform_hidden' \/><input type='hidden' name='input_15.3' value='2' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <!DOCTYPE html PUBLIC \"-\/\/W3C\/\/DTD HTML 4.0 Transitional\/\/EN\" \"http:\/\/www.w3.org\/TR\/REC-html40\/loose.dtd\">\n<?xml encoding=\"UTF-8\"><html><body><input type=\"submit\" id=\"gform_submit_button_1\" class=\"gform_button button\" onclick=\"gform.submission.handleButtonClick(this);\" data-submission-type=\"submit\" value=\"Env&iacute;a\" data-replace-button-html=\"&amp;lt;button type=&amp;quot;submit&amp;quot; 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Es muy f\u00e1cil. \n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' style='display:none'><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: 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12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: 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class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Company<\/label><div class='ginput_container'><input name='input_18' id='input_1_18' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_18'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><\/div><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Iniciales<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Apellido<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_1_5' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_1_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_5_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_5' class='gform_hidden' value='https:\/\/fonkelzorginternational.nl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>G\u00e9nero<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='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Hombre' >Hombre<\/option><option value='Mujer' >Mujer<\/option><option value='Otro \/ no lo dir\u00e1' >Otro \/ no lo dir\u00e1<\/option><\/select><\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Direcci\u00f3n en los Pa\u00edses Bajos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>C\u00f3digo postal en los Pa\u00edses Bajos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>N\u00famero de tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Direcci\u00f3n de correo electr\u00f3nico<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_10' id='input_1_10' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>N\u00famero BSN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Aseguradora<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>AON N\u00famero de p\u00f3liza<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Prueba de identidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_1_12' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Pasaporte neerland\u00e9s' >Pasaporte neerland\u00e9s<\/option><option value='DNI holand\u00e9s' >DNI holand\u00e9s<\/option><option value='Documento de extranjer\u00eda' >Documento de extranjer\u00eda<\/option><option value='Pasaporte extranjero' >Pasaporte extranjero<\/option><\/select><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>N\u00famero del documento de identidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Consentimiento del PSL<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_1_14' class='large gfield_select'  aria-describedby=\"gfield_description_1_14\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='S\u00ed' >S\u00ed<\/option><option value='No' >No<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_14'>\u00bfSe puede compartir tu historial m\u00e9dico en caso de urgencia? \u00bfPueden compartirse tus datos m\u00e9dicos en caso de emergencia? 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