{"id":23,"date":"2023-10-23T12:47:18","date_gmt":"2023-10-23T12:47:18","guid":{"rendered":"https:\/\/hermanus-orthopaedics.co.za\/?page_id=23"},"modified":"2024-08-24T14:01:24","modified_gmt":"2024-08-24T14:01:24","slug":"new-patient-form","status":"publish","type":"page","link":"https:\/\/hermanus-orthopaedics.co.za\/af\/forms\/new-patient-form\/","title":{"rendered":"Aanlyn Pasi\u00ebntvorm"},"content":{"rendered":"<div class=\"wpcf7 no-js\" id=\"wpcf7-f163-o1\" lang=\"en-GB\" dir=\"ltr\" data-wpcf7-id=\"163\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/af\/wp-json\/wp\/v2\/pages\/23#wpcf7-f163-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/af\/wp-json\/wp\/v2\/pages\/23#wpcf7-f163-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"163\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_GB\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f163-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<style>.uacf7-prev, .uacf7-next, .wpcf7-submit{padding-top:px !important; padding-bottom:px !important; padding-left:px !important;  padding-right:px !important;}  <\/style>\t\t\t\t\t<div class=\"uacf7-steps steps-form\" style=\"display:none\">\n\t\t\t\t\t\t<div class=\"steps-row setup-panel\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t<a title-id=\".step-1\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"163\"\n\t\t\t\t\t\t\t\t\t\thref=\"#163step-1\"\n\t\t\t\t\t\t\t\t\t\ttype=\"button\">\n\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t<a title-id=\".step-2\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"163\"\n\t\t\t\t\t\t\t\t\t\thref=\"#163step-2\"\n\t\t\t\t\t\t\t\t\t\ttype=\"button\">\n\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t<a title-id=\".step-3\"\n\t\t\t\t\t\t\t\t\t\tdata-form-id=\"163\"\n\t\t\t\t\t\t\t\t\t\thref=\"#163step-3\"\n\t\t\t\t\t\t\t\t\t\ttype=\"button\">\n\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\t<style>\n\t\t.steps-form .steps-row .steps-step .btn-circle {\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tbackground-color: #f28a5e !important;\t\t\t\t\t\t\t\t}\n\n\t\t.steps-form .steps-row .steps-step .btn-circle img {\n\t\t\tborder-radius: px !important;\t\t}\n\n\t\t.steps-form .steps-row .steps-step .btn-circle.uacf7-btn-active,\n\t\t.steps-form .steps-row .steps-step .btn-circle:hover,\n\t\t.steps-form .steps-row .steps-step .btn-circle:focus,\n\t\t.steps-form .steps-row .steps-step .btn-circle:active {\n\t\t\tbackground-color: #f15f22 !important;\t\t\t\t\t}\n\n\t\t.steps-form .steps-row .steps-step p {\n\t\t\t\t\t}\n\n\t\t.steps-form .steps-row::before {\n\t\t\t\t\t}\n\n\t\t\t<\/style>\n\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"uacf7-steps steps-form\">\n\t\t\t\t\t\t\t<div class=\"steps-row setup-panel\">\n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t\t<a title-id=\".step-1\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"163\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#163step-1\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-active btn-circle\">1\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t<div class=\"steps-info\">\n\t\t\t\t\t\t\t\t\t\t\t<p><\/p>\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t\t<a title-id=\".step-2\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"163\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#163step-2\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\">2\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t<div class=\"steps-info\">\n\t\t\t\t\t\t\t\t\t\t\t<p><\/p>\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t<div class=\"steps-step\">\n\t\t\t\t\t\t\t\t\t\t<a title-id=\".step-3\"\n\t\t\t\t\t\t\t\t\t\t\tdata-form-id=\"163\"\n\t\t\t\t\t\t\t\t\t\t\thref=\"#163step-3\" type=\"button\"\n\t\t\t\t\t\t\t\t\t\t\tclass=\"btn uacf7-btn-default btn-circle\">3\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t<div class=\"steps-info\">\n\t\t\t\t\t\t\t\t\t\t\t<p><\/p>\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"uacf7-multisetp-form\">\n\t\t\t\t\t<div class=\"uacf7-form-wrapper-container uacf7-form-163\">\t\t<div class=\"uacf7-step uacf7-step-163 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<div class=\"contact\">\n<h3>HOOFLID INLIGTING:<\/h3>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>ID NOMMER <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"id-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"id-number\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>VAN <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-12\">\n<h6>VOLLE NAME <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"full-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"full-name\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-3\">\n<h6>VOORLETTERS<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"initials\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"initials\" \/><\/span>\n<\/div><div class=\"col-md-3\">\n<h6>GESLAG<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gender\" value=\"M\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">M<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gender\" value=\"F\" \/><span class=\"wpcf7-list-item-label\">F<\/span><\/label><\/span><\/span><\/span>\n<\/div><div class=\"col-md-3\">\n<h6>TITEL<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title\" \/><\/span>\n<\/div><div class=\"col-md-3\">\n<h6>GEBOORTE DATUM <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"JJJJ\/MM\/DD\" value=\"\" type=\"date\" name=\"birthday\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-4\">\n<h6>SELNOMMER <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cell-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"cell-number\" \/><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>HUISNOMMER<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"home-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"home-number\" \/><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>WERKNOMMER<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"work-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"work-number\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-8\">\n<h6>E-POS ADRES <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>E-POS VERKLARING?<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"statement\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"statement\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"statement\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-8\">\n<h6>POSADRES <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"postal-address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"postal-address\"><\/textarea><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>POSKODE <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"postal-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"postal-code\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-8\">\n<h6>FISIESE ADRES<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"physical-address\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"physical-address\"><\/textarea><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>POSKODE<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"physical-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physical-code\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-12\">\n<h6>MEDIESE SKEMA<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medial-scheme\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medial-scheme\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-8\">\n<h6>BEPLAN\/OPSIE<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"plan-option\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plan-option\" \/><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>GAP DEKKING?<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gap-cover\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"gap-cover\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"gap-cover\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-8\">\n<h6>LID NR<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"member-no\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"member-no\" \/><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>HOOFLIDAFHANKLIKE KODE<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"member-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"member-code\" \/><\/span>\n<\/div><\/div>\n<\/div>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"163\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"163\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"uacf7-step uacf7-step-163 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<div class=\"contact\">\n<h3>PATIENT INFORMATION<\/h3>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>ID NOMMER <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-id-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-id-number\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>VAN <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-last-name\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>VOLLE NAME <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-full-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-full-name\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>BYNAAM<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-nickname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-nickname\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-3\">\n<h6>VOORLETTERS<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-initials\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-initials\" \/><\/span>\n<\/div><div class=\"col-md-3\">\n<h6>GESLAG<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"patient-gender\" value=\"M\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">M<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"patient-gender\" value=\"F\" \/><span class=\"wpcf7-list-item-label\">F<\/span><\/label><\/span><\/span><\/span>\n<\/div><div class=\"col-md-3\">\n<h6>TITEL<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-title\" \/><\/span>\n<\/div><div class=\"col-md-3\">\n<h6>GEBOORTE DATUM <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"JJJJ\/MM\/DD\" value=\"\" type=\"date\" name=\"patient-birthday\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>SELNOMMER <span>*<\/span><\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-cell-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"patient-cell-number\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>Gebruik hierdie nommer vir afsprake \/ toetsuitslae?<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"used-number\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"used-number\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Ja<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"used-number\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">Nee<\/span><\/label><\/span><\/span><\/span>\n<br\/>\n<small>Hooflid se selfoonnommer sal gebruik word indien bogenoemde is Nee<\/small>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>HUISNOMMER<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-home-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"patient-home-number\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>WERKNOMMER<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-work-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"patient-work-number\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-12\">\n<h6>E-POS ADRES<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"patient-email\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>BEROEP<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-occupation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-occupation\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>HUWELIKSTATUS<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-marital-status\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"patient-marital-status\"><option value=\"Married\">Married<\/option><option value=\"Widowed\">Widowed<\/option><option value=\"Divorced\">Divorced<\/option><option value=\"Single\">Single<\/option><\/select><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>VERHOUDING MET HOOFLID<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-relationship\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>PASI\u00cbNTAFHANKLIKE KODE<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-code\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-4\">\n<h6>OUDERDOM<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-age\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"00 jare\" value=\"\" type=\"text\" name=\"patient-age\" \/><\/span> \n<\/div><div class=\"col-md-4\">\n<h6>HOOGTE<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-height\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"0.00M\" value=\"\" type=\"text\" name=\"patient-height\" \/><\/span>\n<\/div><div class=\"col-md-4\">\n<h6>GEWIG<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-weight\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"00Kg\" value=\"\" type=\"text\" name=\"patient-weight\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>VERWYS DR<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referring-dr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referring-dr\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>TEL. NR<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referring-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"referring-tel\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>HUISDOKTER<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gp\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"gp\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>TEL. NR<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"gp-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"gp-tel\" \/><\/span>\n<\/div><\/div>\n<\/div>\n\t\t\t<p class=\"uacf7-buttons\">\n\t\t\t\t<button class=\"uacf7-prev\"\n\t\t\t\t\tdata-form-id=\"163\">Previous<\/button>\n\t\t\t\t<button class=\"uacf7-next\"\n\t\t\t\t\tdata-form-id=\"163\">Next<\/button>\n\t\t\t\t<span class=\"wpcf7-spinner uacf7-ajax-loader\"><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t\n\t\t<div class=\"uacf7-step uacf7-step-163 step-content\"\n\t\t\tnext-btn-text=\"Next\" prev-btn-text=\"Previous\">\n\t\t\t\n<div class=\"contact\">\n<h3>NAAMSTAANDE<\/h3>\n<p><em>Nie van dieselfde fisiese adres nie<\/em><\/p>\n<div class=\"row\"><div class=\"col-md-3\">\n<h6>VOORLETTERS<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kin-initials\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kin-initials\" \/><\/span>\n<\/div><div class=\"col-md-3\">\n<h6>TITEL<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kin-title\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kin-title\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>VAN<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kin-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kin-last-name\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-12\">\n<h6>VOLLE NAME<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kin-full-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kin-full-name\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-6\">\n<h6>SELNOMMER<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kin-cell\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"kin-cell\" \/><\/span>\n<\/div><div class=\"col-md-6\">\n<h6>VERHOUDING TOT PASI\u00cbNT<\/h6>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"kin-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kin-relationship\" \/><\/span>\n<\/div><\/div>\n<div class=\"row\"><div class=\"col-md-12\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"terms\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"terms\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\"><em>Deur hierdie vorm in te dien, bevestig ek dat die inligting wat ek verskaf het waar is en dat ek verantwoordelik is vir enige vals inligting wat verskaf word.<\/em><\/span><\/label><\/span><\/span><\/span>\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Stuur\" \/>\n<\/div><\/div>\n<\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"af\"\/><\/form>\n<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":21,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_kad_post_transparent":"default","_kad_post_title":"default","_kad_post_layout":"narrow","_kad_post_sidebar_id":"","_kad_post_content_style":"default","_kad_post_vertical_padding":"default","_kad_post_feature":"","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"_kad_post_classname":"","footnotes":""},"class_list":["post-23","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/pages\/23","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/comments?post=23"}],"version-history":[{"count":2,"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/pages\/23\/revisions"}],"predecessor-version":[{"id":164,"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/pages\/23\/revisions\/164"}],"up":[{"embeddable":true,"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/pages\/21"}],"wp:attachment":[{"href":"https:\/\/hermanus-orthopaedics.co.za\/af\/wp-json\/wp\/v2\/media?parent=23"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}