{"id":30,"date":"2018-11-09T12:44:47","date_gmt":"2018-11-09T12:44:47","guid":{"rendered":"http:\/\/verloskundigenpraktijkbijlmermeer.nl\/?page_id=30"},"modified":"2022-06-27T14:37:05","modified_gmt":"2022-06-27T12:37:05","slug":"aanmelden","status":"publish","type":"page","link":"https:\/\/www.verloskundigenpraktijkbijlmermeer.nl\/nl\/aanmelden\/","title":{"rendered":"Aanmelden"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_fullwidth_slider _builder_version=&#8221;4.16&#8243; custom_margin=&#8221;|0px||0px&#8221; custom_padding=&#8221;|0px||0px&#8221; global_colors_info=&#8221;{}&#8221; button_text_size__hover_enabled=&#8221;off&#8221; button_one_text_size__hover_enabled=&#8221;off&#8221; button_two_text_size__hover_enabled=&#8221;off&#8221; button_text_color__hover_enabled=&#8221;off&#8221; button_one_text_color__hover_enabled=&#8221;off&#8221; button_two_text_color__hover_enabled=&#8221;off&#8221; 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use_background_color_gradient=&#8221;on&#8221; background_color_gradient_direction=&#8221;63deg&#8221; background_color_gradient_stops=&#8221;#5c4043 1%|rgba(41,196,169,0) 47%&#8221; background_color_gradient_overlays_image=&#8221;on&#8221; background_color_gradient_start=&#8221;#5c4043&#8243; background_color_gradient_start_position=&#8221;1%&#8221; background_color_gradient_end=&#8221;rgba(41,196,169,0)&#8221; background_color_gradient_end_position=&#8221;47%&#8221; background_image=&#8221;https:\/\/verloskundigenpraktijkbijlmermeer.nl\/wp-content\/uploads\/2018\/11\/Verloskundigenpraktijk-Bijlmermeer-Slapende-baby.jpg&#8221; button_on_hover=&#8221;on&#8221; text_orientation=&#8221;left&#8221; custom_padding=&#8221;100px||100px|&#8221; custom_padding_tablet=&#8221;100px||100px|&#8221; custom_padding_phone=&#8221;100px||100px|&#8221; body_line_height_tablet=&#8221;1.8em&#8221; body_line_height_phone=&#8221;1.8em&#8221; global_colors_info=&#8221;{}&#8221; button_text_size__hover_enabled=&#8221;off&#8221; button_one_text_size__hover_enabled=&#8221;off&#8221; button_two_text_size__hover_enabled=&#8221;off&#8221; button_text_color__hover_enabled=&#8221;off&#8221; button_one_text_color__hover_enabled=&#8221;off&#8221; button_two_text_color__hover_enabled=&#8221;off&#8221; button_border_width__hover_enabled=&#8221;off&#8221; button_one_border_width__hover_enabled=&#8221;off&#8221; button_two_border_width__hover_enabled=&#8221;off&#8221; button_border_color__hover_enabled=&#8221;off&#8221; button_one_border_color__hover_enabled=&#8221;off&#8221; button_two_border_color__hover_enabled=&#8221;off&#8221; button_border_radius__hover_enabled=&#8221;off&#8221; button_one_border_radius__hover_enabled=&#8221;off&#8221; button_two_border_radius__hover_enabled=&#8221;off&#8221; button_letter_spacing__hover_enabled=&#8221;off&#8221; button_one_letter_spacing__hover_enabled=&#8221;off&#8221; button_two_letter_spacing__hover_enabled=&#8221;off&#8221; button_bg_color__hover_enabled=&#8221;off&#8221; button_one_bg_color__hover_enabled=&#8221;off&#8221; button_two_bg_color__hover_enabled=&#8221;off&#8221; sticky_transition=&#8221;on&#8221;][\/et_pb_slide][\/et_pb_fullwidth_slider][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; module_id=&#8221;leefadviezen&#8221; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row column_structure=&#8221;1_2,1_2&#8243; make_equal=&#8221;on&#8221; _builder_version=&#8221;4.17.4&#8243; width=&#8221;65%&#8221; width_tablet=&#8221;65%&#8221; width_phone=&#8221;95%&#8221; width_last_edited=&#8221;on|phone&#8221; max_width=&#8221;65%&#8221; max_width_tablet=&#8221;65%&#8221; max_width_phone=&#8221;100%&#8221; max_width_last_edited=&#8221;on|phone&#8221; custom_padding=&#8221;0|0px|0|0px|false|false&#8221; custom_css_main_element=&#8221;align-items:center;&#8221; use_custom_width=&#8221;on&#8221; width_unit=&#8221;off&#8221; custom_width_percent=&#8221;65%&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.17.4&#8243; link_font=&#8221;||||on||||&#8221; link_text_color=&#8221;#004A9A&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Aanmelden bij Verloskundigenpraktijk Bijlmermeer?<\/h2>\n<p>Wanneer u zich wil inschrijven bij onze praktijk, vul dan onderstaande gegevens in en wij nemen zo spoedig mogelijk contact met u op.<\/p>\n<p>Mocht je vragen hebben? Dan zijn wij te bereiken via de onderstaande contactgegevens:<\/p>\n<p><strong>Telefoon:<\/strong>\u00a0<a href=\"tel:0206950997\">020-6950997<\/a><br \/><strong>E-mailadres:<\/strong> <a href=\"mailto:info@verloskundigenpraktijkbijlmermeer.nl\">info@verloskundigenpraktijkbijlmermeer.nl<\/a><\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=&#8221;1_2&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_image src=&#8221;https:\/\/verloskundigenpraktijkbijlmermeer.nl\/wp-content\/uploads\/2022\/06\/Verloskundigenpraktijk-Bijlmermeer-Praktijk-Gesprek-Groot-1024&#215;576.jpeg&#8221; alt=&#8221;Aanmelden bij Verloskundigenpraktijk Bijlmermeer&#8221; title_text=&#8221;Verloskundigenpraktijk-Bijlmermeer-Praktijk-Gesprek Groot&#8221; _builder_version=&#8221;4.17.4&#8243; _module_preset=&#8221;default&#8221; 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gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/nl\/wp-json\/wp\/v2\/pages\/30' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_23\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'><span class='gform-field-label__text'>X\/Twitter<\/span><\/label><div class='gfield_description' id='gfield_description_1_23'>Dit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.<\/div><div class='ginput_container'><input name='input_23' id='input_1_23' type='text' value='' autocomplete='new-password'\/><\/div><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Namen<\/span><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_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 '>Voornaam<\/label>\n                                                <\/span>\n                            \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 '>Achternaam<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Meisjesnaam<\/span><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 no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_2'>\n                            \n                            \n                            \n                            <span id='input_1_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_1_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_2_6' class='gform-field-label gform-field-label--type-sub '>Meisjesnaam<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Roepnaam<\/span><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_1_3'>\n                            \n                            <span id='input_1_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_3_3' class='gform-field-label gform-field-label--type-sub '>Roepnaam<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Adres<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city ginput_container_address gform-grid-row' id='input_1_13' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_13_1_container' >\n                                        <input type='text' name='input_13.1' id='input_1_13_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_13_1' id='input_1_13_1_label' class='gform-field-label gform-field-label--type-sub '>Straat + huisnummer<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_13_2_container' >\n                                        <input type='text' name='input_13.2' id='input_1_13_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_13_2' id='input_1_13_2_label' class='gform-field-label gform-field-label--type-sub '>Woonplaats<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_13_3_container' >\n                                    <input type='text' name='input_13.3' id='input_1_13_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_13_3' id='input_1_13_3_label' class='gform-field-label gform-field-label--type-sub '>Plaats<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_13.4' id='input_1_13_4' value=''\/><input type='hidden' class='gform_hidden' name='input_13.6' id='input_1_13_6' value='NL' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-phone gfield--phone-format-standard field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'><span class='gform-field-label__text'>Telefoon Thuis<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_1_14' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'><span class='gform-field-label__text'>Mobiel<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_1_15' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'><span class='gform-field-label__text'>E-mailadres<\/span><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_16' id='input_1_16' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'><span class='gform-field-label__text'>Geboortedatum<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/jjjj'\n\t\t\t\t\tid='input_1_4'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_4'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_4' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_4' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_4' aria-label='Geboortedatum: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'><span class='gform-field-label__text'>Burger Service Nummer (BSN)<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_5' id='input_1_5' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Bent u al bekend bij ons in de praktijk<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_6'><li class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Ja'  id='choice_1_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Nee'  id='choice_1_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_2' id='label_1_6_2' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'><span class='gform-field-label__text'>Wie is uw huisarts?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'><span class='gform-field-label__text'>Verzekeringsmaatschappij<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'><span class='gform-field-label__text'>Polisnummer<\/span><\/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_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'><span class='gform-field-label__text'>Achternaam partner<\/span><\/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-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'><span class='gform-field-label__text'>Voorletters partner<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'><span class='gform-field-label__text'>Roepnaam partner<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'><span class='gform-field-label__text'>Burgerlijke staat<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_1_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Alleenstaand' >Alleenstaand<\/option><option value='Samenwonend' >Samenwonend<\/option><option value='Getrouwd' >Getrouwd<\/option><option value='LAT' >LAT<\/option><option value='Gescheiden' >Gescheiden<\/option><\/select><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'><span class='gform-field-label__text'>1e dag van uw menstruatie<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/jjjj'\n\t\t\t\t\tid='input_1_18'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_18'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_18' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_18' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_18' aria-label='1e dag van uw menstruatie: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'><span class='gform-field-label__text'>Cyclus<\/span><\/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='Regelmatig' >Regelmatig<\/option><option value='Onregelmatig' >Onregelmatig<\/option><\/select><\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'><span class='gform-field-label__text'>Hoeveelste zwangerschap<\/span><\/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='1e' >1e<\/option><option value='2e' >2e<\/option><option value='3e' >3e<\/option><option value='4e' >4e<\/option><option value='5e' >5e<\/option><option value='6e' >6e<\/option><option value='7e' >7e<\/option><option value='8e' >8e<\/option><option value='9e' >9e<\/option><option value='10e' >10e<\/option><\/select><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'><span class='gform-field-label__text'>Hoeveelste kindje<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_1_21' class='medium gfield_select'     aria-invalid=\"false\" ><option value='1e' >1e<\/option><option value='2e' >2e<\/option><option value='3e' >3e<\/option><option value='4e' >4e<\/option><option value='5e' >5e<\/option><option value='6e' >6e<\/option><option value='7e' >7e<\/option><option value='8e' >8e<\/option><option value='9e' >9e<\/option><option value='10e' >10e<\/option><\/select><\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'><span class='gform-field-label__text'>Bijzonderheden<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Verzenden<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\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_currency' data-currency='USD' value='kf+ZHpEvls3FBk29DwMYKsKgBD8Ag\/8NtB5FYXeVI7i2QYuZDMxUTTUO8v3IunkyObZeyiaJCRQt5OrA39QVq8p6ZGnmbvZEh\/IqKFBSr7\/tq5k=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' 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                        <\/form>\n                        <\/div>[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Aanmelden bij Verloskundigenpraktijk Bijlmermeer? Wanneer u zich wil inschrijven bij onze praktijk, vul dan onderstaande gegevens in en wij nemen zo spoedig mogelijk contact met u op. Mocht je vragen hebben? Dan zijn wij te bereiken via de onderstaande contactgegevens: Telefoon:\u00a0020-6950997E-mailadres: info@verloskundigenpraktijkbijlmermeer.nl\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\">Aanmeldformulier<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/nl\/wp-json\/wp\/v2\/pages\/30' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_23\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'><span class='gform-field-label__text'>Facebook<\/span><\/label><div class='gfield_description' id='gfield_description_1_23'>Dit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.<\/div><div class='ginput_container'><input name='input_23' id='input_1_23' type='text' value='' autocomplete='new-password'\/><\/div><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Namen<\/span><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_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 '>Voornaam<\/label>\n                                                <\/span>\n                            \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 '>Achternaam<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Meisjesnaam<\/span><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 no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_2'>\n                            \n                            \n                            \n                            <span id='input_1_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_1_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_2_6' class='gform-field-label gform-field-label--type-sub '>Meisjesnaam<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Roepnaam<\/span><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_1_3'>\n                            \n                            <span id='input_1_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_3_3' class='gform-field-label gform-field-label--type-sub '>Roepnaam<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Adres<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city ginput_container_address gform-grid-row' id='input_1_13' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_13_1_container' >\n                                        <input type='text' name='input_13.1' id='input_1_13_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_13_1' id='input_1_13_1_label' class='gform-field-label gform-field-label--type-sub '>Straat + huisnummer<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_13_2_container' >\n                                        <input type='text' name='input_13.2' id='input_1_13_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_13_2' id='input_1_13_2_label' class='gform-field-label gform-field-label--type-sub '>Woonplaats<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_13_3_container' >\n                                    <input type='text' name='input_13.3' id='input_1_13_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_13_3' id='input_1_13_3_label' class='gform-field-label gform-field-label--type-sub '>Plaats<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_13.4' id='input_1_13_4' value=''\/><input type='hidden' class='gform_hidden' name='input_13.6' id='input_1_13_6' value='NL' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-phone gfield--phone-format-standard field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'><span class='gform-field-label__text'>Telefoon Thuis<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_1_14' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-phone gfield--phone-format-standard gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'><span class='gform-field-label__text'>Mobiel<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_1_15' type='tel' value='' class='medium'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'><span class='gform-field-label__text'>E-mailadres<\/span><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_16' id='input_1_16' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'><span class='gform-field-label__text'>Geboortedatum<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/jjjj'\n\t\t\t\t\tid='input_1_4'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_4'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_4' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_4' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_4' aria-label='Geboortedatum: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'><span class='gform-field-label__text'>Burger Service Nummer (BSN)<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_5' id='input_1_5' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Bent u al bekend bij ons in de praktijk<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_6'><li class='gchoice gchoice_1_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Ja'  id='choice_1_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_1' id='label_1_6_1' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Nee'  id='choice_1_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_6_2' id='label_1_6_2' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_7\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'><span class='gform-field-label__text'>Wie is uw huisarts?<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'><span class='gform-field-label__text'>Verzekeringsmaatschappij<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'><span class='gform-field-label__text'>Polisnummer<\/span><\/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_10\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'><span class='gform-field-label__text'>Achternaam partner<\/span><\/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-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'><span class='gform-field-label__text'>Voorletters partner<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'><span class='gform-field-label__text'>Roepnaam partner<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'><span class='gform-field-label__text'>Burgerlijke staat<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_1_17' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Alleenstaand' >Alleenstaand<\/option><option value='Samenwonend' >Samenwonend<\/option><option value='Getrouwd' >Getrouwd<\/option><option value='LAT' >LAT<\/option><option value='Gescheiden' >Gescheiden<\/option><\/select><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'><span class='gform-field-label__text'>1e dag van uw menstruatie<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/jjjj'\n\t\t\t\t\tid='input_1_18'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_18'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_18' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_18' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_18' aria-label='1e dag van uw menstruatie: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'><span class='gform-field-label__text'>Cyclus<\/span><\/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='Regelmatig' >Regelmatig<\/option><option value='Onregelmatig' >Onregelmatig<\/option><\/select><\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'><span class='gform-field-label__text'>Hoeveelste zwangerschap<\/span><\/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='1e' >1e<\/option><option value='2e' >2e<\/option><option value='3e' >3e<\/option><option value='4e' >4e<\/option><option value='5e' >5e<\/option><option value='6e' >6e<\/option><option value='7e' >7e<\/option><option value='8e' >8e<\/option><option value='9e' >9e<\/option><option value='10e' >10e<\/option><\/select><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'><span class='gform-field-label__text'>Hoeveelste kindje<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_1_21' class='medium gfield_select'     aria-invalid=\"false\" ><option value='1e' >1e<\/option><option value='2e' >2e<\/option><option value='3e' >3e<\/option><option value='4e' >4e<\/option><option value='5e' >5e<\/option><option value='6e' >6e<\/option><option value='7e' >7e<\/option><option value='8e' >8e<\/option><option value='9e' >9e<\/option><option value='10e' >10e<\/option><\/select><\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'><span class='gform-field-label__text'>Bijzonderheden<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Verzenden<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\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_currency' data-currency='USD' value='dwyk3ApehNopZ5aK1uNn7POzS\/lJf7m\/yxKeUPvsd2y9S\/MDLwcY1Jfwjl5avKZJhX1TilHRkuzVkjz0LCscl0ap\/tzCix2kdGbbGVw1G4Z8ZE4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' 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                        <\/form>\n                        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