{"id":6658,"date":"2025-02-05T21:52:52","date_gmt":"2025-02-05T18:52:52","guid":{"rendered":"https:\/\/qualitylifehealth.com\/form\/"},"modified":"2025-02-05T21:52:52","modified_gmt":"2025-02-05T18:52:52","slug":"form","status":"publish","type":"page","link":"https:\/\/qualitylifehealth.com\/es\/form\/","title":{"rendered":"Hasta Kay\u0131t Formu"},"content":{"rendered":"[vc_row type=\u00bbfull_width_background\u00bb full_screen_row_position=\u00bbmiddle\u00bb column_margin=\u00bbdefault\u00bb column_direction=\u00bbdefault\u00bb column_direction_tablet=\u00bbdefault\u00bb column_direction_phone=\u00bbdefault\u00bb bg_color=\u00bb#000000&#8243; scene_position=\u00bbcenter\u00bb text_color=\u00bbdark\u00bb text_align=\u00bbleft\u00bb row_border_radius=\u00bbnone\u00bb row_border_radius_applies=\u00bbbg\u00bb overflow=\u00bbvisible\u00bb overlay_strength=\u00bb0.3&#8243; gradient_direction=\u00bbleft_to_right\u00bb shape_divider_position=\u00bbbottom\u00bb bg_image_animation=\u00bbnone\u00bb gradient_type=\u00bbdefault\u00bb shape_type=\u00bb\u00bb][vc_column column_padding=\u00bbno-extra-padding\u00bb column_padding_tablet=\u00bbinherit\u00bb column_padding_phone=\u00bbinherit\u00bb column_padding_position=\u00bball\u00bb column_element_direction_desktop=\u00bbdefault\u00bb column_element_spacing=\u00bbdefault\u00bb desktop_text_alignment=\u00bbdefault\u00bb tablet_text_alignment=\u00bbdefault\u00bb phone_text_alignment=\u00bbdefault\u00bb background_color_opacity=\u00bb1&#8243; background_hover_color_opacity=\u00bb1&#8243; column_backdrop_filter=\u00bbnone\u00bb column_shadow=\u00bbnone\u00bb column_border_radius=\u00bbnone\u00bb column_link_target=\u00bb_self\u00bb column_position=\u00bbdefault\u00bb gradient_direction=\u00bbleft_to_right\u00bb overlay_strength=\u00bb0.3&#8243; width=\u00bb1\/1&#8243; tablet_width_inherit=\u00bbdefault\u00bb animation_type=\u00bbdefault\u00bb bg_image_animation=\u00bbnone\u00bb border_type=\u00bbsimple\u00bb column_border_width=\u00bbnone\u00bb column_border_style=\u00bbsolid\u00bb column_padding_type=\u00bbdefault\u00bb gradient_type=\u00bbdefault\u00bb offset=\u00bbvc_hidden-sm vc_hidden-xs\u00bb]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6630-o1\" lang=\"es-ES\" dir=\"ltr\" data-wpcf7-id=\"6630\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/6658#wpcf7-f6630-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulario de contacto\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"6630\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6630-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div style=\"display: flex; flex-direction: column; gap: 16px; font-size: 22px;\">\n\t<div style=\"display: inline-flex; gap: 8px;\">\n\t\t<div class=\"vc_col-sm-6\" style=\"font-size: 22px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre Completo\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"vc_col-sm-6\" style=\"font-size: 22px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"passport-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"N\u00famero de Pasaporte:\" value=\"\" type=\"text\" name=\"passport-number\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div style=\"display: inline-flex; gap: 8px;\">\n\t\t<p style=\"color:white; font-size: 22px;\">Fecha de llegada para tratamiento en Estambul\n\t\t<\/p>\n\t\t<div class=\"vc_col-sm-12\" style=\"font-size: 22px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-date-gelis\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"treatment-date-gelis\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p style=\"color:white; font-size: 22px;\">Fecha de salida de Estambul\n\t\t<\/p>\n\t\t<div class=\"vc_col-sm-12\" style=\"font-size: 22px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-date-gidis\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"treatment-date-gidis\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px;\">\u00bfTiene el h\u00e1bito de consumir alcohol? \u00bfCon qu\u00e9 frecuencia?\n\t<\/p>\n\t<div class=\"col-md-12 alkol-checkbox\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-8\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-8\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Todos los d\u00edas\" \/><span class=\"wpcf7-list-item-label\">Todos los d\u00edas<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Cada dos d\u00edas\" \/><span class=\"wpcf7-list-item-label\">Cada dos d\u00edas<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Una vez a la semana\" \/><span class=\"wpcf7-list-item-label\">Una vez a la semana<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-8\" value=\"Una vez al mes\" \/><span class=\"wpcf7-list-item-label\">Una vez al mes<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px; margin-top:20px;\">\u00bfGru\u00f1e los dientes?\n\t<\/p>\n\t<div class=\"col-md-12 dis-g\u0131c\u0131rdatma-checkbox\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-673\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-673\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-673\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px; margin-top:20px;\">\u00bfEs al\u00e9rgico a los antibi\u00f3ticos?\n\t<\/p>\n\t<div class=\"col-md-12 antibiyotik-checkbox\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-674\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-674\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-674\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div style=\"display: inline-flex; gap: 8px;\">\n\t\t<div class=\"vc_col-sm-12\" style=\"font-size: 22px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"current-treatment\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u00bfEst\u00e1 recibiendo tratamiento actualmente?\" value=\"\" type=\"text\" name=\"current-treatment\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"vc_col-sm-12\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medication\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u00bfEst\u00e1 tomando medicamentos?\" value=\"\" type=\"text\" name=\"medication\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"vc_col-sm-12\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"disease-history\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u00bfTiene alguna enfermedad o historial m\u00e9dico?\" value=\"\" type=\"text\" name=\"disease-history\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-12 diseases-checkbox\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diseases\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Enfermedades del coraz\u00f3n\" \/><span class=\"wpcf7-list-item-label\">Enfermedades del coraz\u00f3n<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Problemas de presi\u00f3n arterial\" \/><span class=\"wpcf7-list-item-label\">Problemas de presi\u00f3n arterial<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Fiebre reum\u00e1tica\" \/><span class=\"wpcf7-list-item-label\">Fiebre reum\u00e1tica<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Bocio (medicamentos para la tiroides)\" \/><span class=\"wpcf7-list-item-label\">Bocio (medicamentos para la tiroides)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Alergias (medicamentos, alimentos, etc.)\" \/><span class=\"wpcf7-list-item-label\">Alergias (medicamentos, alimentos, etc.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Hepatitis\" \/><span class=\"wpcf7-list-item-label\">Hepatitis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Trastornos renales o hep\u00e1ticos\" \/><span class=\"wpcf7-list-item-label\">Trastornos renales o hep\u00e1ticos<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Sinusitis\" \/><span class=\"wpcf7-list-item-label\">Sinusitis<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Enfermedades infecciosas (Hepatitis, SIDA, etc.)\" \/><span class=\"wpcf7-list-item-label\">Enfermedades infecciosas (Hepatitis, SIDA, etc.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Epilepsia (convulsiones)\" \/><span class=\"wpcf7-list-item-label\">Epilepsia (convulsiones)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Artritis reumatoide\" \/><span class=\"wpcf7-list-item-label\">Artritis reumatoide<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Trastornos sangu\u00edneos\" \/><span class=\"wpcf7-list-item-label\">Trastornos sangu\u00edneos<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Enfermedades de la piel\" \/><span class=\"wpcf7-list-item-label\">Enfermedades de la piel<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Asma, fiebre del heno\" \/><span class=\"wpcf7-list-item-label\">Asma, fiebre del heno<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Enfermedades pulmonares\" \/><span class=\"wpcf7-list-item-label\">Enfermedades pulmonares<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Diagn\u00f3stico de c\u00e1ncer\" \/><span class=\"wpcf7-list-item-label\">Diagn\u00f3stico de c\u00e1ncer<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"vc_col-sm-12\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-medical-issues\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u00bfTiene otros problemas m\u00e9dicos?\" value=\"\" type=\"text\" name=\"other-medical-issues\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-12\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consent\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"consent[]\" value=\"Acepto la exactitud de la informaci\u00f3n anterior.\" \/><span class=\"wpcf7-list-item-label\">Acepto la exactitud de la informaci\u00f3n 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gradient_type=\u00bbdefault\u00bb shape_type=\u00bb\u00bb][vc_column column_padding=\u00bbno-extra-padding\u00bb column_padding_tablet=\u00bbinherit\u00bb column_padding_phone=\u00bbinherit\u00bb column_padding_position=\u00bball\u00bb column_element_direction_desktop=\u00bbdefault\u00bb column_element_spacing=\u00bbdefault\u00bb desktop_text_alignment=\u00bbdefault\u00bb tablet_text_alignment=\u00bbdefault\u00bb phone_text_alignment=\u00bbdefault\u00bb background_color_opacity=\u00bb1&#8243; background_hover_color_opacity=\u00bb1&#8243; column_backdrop_filter=\u00bbnone\u00bb column_shadow=\u00bbnone\u00bb column_border_radius=\u00bbnone\u00bb column_link_target=\u00bb_self\u00bb column_position=\u00bbdefault\u00bb gradient_direction=\u00bbleft_to_right\u00bb overlay_strength=\u00bb0.3&#8243; width=\u00bb1\/1&#8243; tablet_width_inherit=\u00bbdefault\u00bb animation_type=\u00bbdefault\u00bb bg_image_animation=\u00bbnone\u00bb border_type=\u00bbsimple\u00bb column_border_width=\u00bbnone\u00bb column_border_style=\u00bbsolid\u00bb column_padding_type=\u00bbdefault\u00bb gradient_type=\u00bbdefault\u00bb offset=\u00bbvc_hidden-lg vc_hidden-md\u00bb]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6644-o2\" lang=\"es-ES\" dir=\"ltr\" data-wpcf7-id=\"6644\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/6658#wpcf7-f6644-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulario de contacto\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"6644\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6644-o2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div style=\"display: flex; flex-direction: column; gap: 16px; font-size: 24px;\">\n <!-- Ad Soyad, Pasaport No, Telefon No -->\n\t<div style=\"display: inline-flex; gap: 8px;\">\n\t\t<div class=\"vc_col-sm-6\" style=\"font-size: 24px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ad Soyad\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"vc_col-sm-6\" style=\"font-size: 24px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"passport-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Pasaport No:\" value=\"\" type=\"text\" name=\"passport-number\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p style=\"color:white; margin-bottom:-20px; font-size: 24px;\">\u0130stanbul'a Tedaviye Geli\u015f Tarihi\n\t<\/p>\n\t<div style=\"display: inline-flex; gap: 8px;\">\n\t\t<div class=\"vc_col-sm-12\" style=\"font-size: 24px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-date-gelis\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"treatment-date-gelis\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p style=\"color:white; margin-bottom:-20px; font-size: 24px;\">\u0130stanbul'dan Gidi\u015f Tarihi\n\t<\/p>\n\t<div style=\"display: inline-flex; gap: 8px;\">\n\t\t<div class=\"vc_col-sm-12\" style=\"font-size: 24px;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-date-gidis\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"treatment-date-gidis\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\n<!-- Alkol al\u0131\u015fkanl\u0131\u011f\u0131 (Radio Button) -->\n\t<div class=\"col-md-12 alkol-checkbox\" style=\"font-size: 22px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-8\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-8\" value=\"Yok\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yok<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Her g\u00fcn\" \/><span class=\"wpcf7-list-item-label\">Her g\u00fcn<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"\u0130ki g\u00fcnde bir\" \/><span class=\"wpcf7-list-item-label\">\u0130ki g\u00fcnde bir<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Haftada bir\" \/><span class=\"wpcf7-list-item-label\">Haftada bir<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-8\" value=\"Ayda bir\" \/><span class=\"wpcf7-list-item-label\">Ayda bir<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\n\n <!-- \u015eu anda tedavi, ila\u00e7 durumu ve hastal\u0131klar -->\n\t<div class=\"vc_col-sm-12\" style=\"font-size: 24px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"current-treatment\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u015eu anda herhangi bir tedavi g\u00f6r\u00fcyor musunuz?\" value=\"\" type=\"text\" name=\"current-treatment\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"vc_col-sm-12\" style=\"font-size: 24px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medication\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u0130la\u00e7 kullan\u0131yor musunuz?\" value=\"\" type=\"text\" name=\"medication\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"vc_col-sm-12\" style=\"font-size: 24px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"disease-history\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Herhangi bir hastal\u0131\u011f\u0131n\u0131z var m\u0131, ge\u00e7irdiniz mi?\" value=\"\" type=\"text\" name=\"disease-history\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\n <!-- Hastal\u0131klar (Checkbox) -->\n\t<div class=\"col-md-12 diseases-checkbox\" style=\"font-size: 24px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"diseases\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Kalp hastal\u0131klar\u0131\" \/><span class=\"wpcf7-list-item-label\">Kalp hastal\u0131klar\u0131<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Tansiyon sorunu\" \/><span class=\"wpcf7-list-item-label\">Tansiyon sorunu<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Ate\u015fli romatizma\" \/><span class=\"wpcf7-list-item-label\">Ate\u015fli romatizma<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Guatr (Troid tabletleri)\" \/><span class=\"wpcf7-list-item-label\">Guatr (Troid tabletleri)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Alerjisi (ila\u00e7, besin vb.)\" \/><span class=\"wpcf7-list-item-label\">Alerjisi (ila\u00e7, besin vb.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Sar\u0131l\u0131k\" \/><span class=\"wpcf7-list-item-label\">Sar\u0131l\u0131k<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"B\u00f6brek karaci\u011fer bozukluklar\u0131\" \/><span class=\"wpcf7-list-item-label\">B\u00f6brek karaci\u011fer bozukluklar\u0131<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Sin\u00fczit\" \/><span class=\"wpcf7-list-item-label\">Sin\u00fczit<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Bula\u015f\u0131c\u0131 Hastal\u0131klar (Hepatit, AIDS vb.)\" \/><span class=\"wpcf7-list-item-label\">Bula\u015f\u0131c\u0131 Hastal\u0131klar (Hepatit, AIDS vb.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u015eeker hastal\u0131\u011f\u0131\" \/><span class=\"wpcf7-list-item-label\">\u015eeker hastal\u0131\u011f\u0131<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Epilepsi (sara)\" \/><span class=\"wpcf7-list-item-label\">Epilepsi (sara)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Eklem romatizmas\u0131\" \/><span class=\"wpcf7-list-item-label\">Eklem romatizmas\u0131<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Kan hastal\u0131klar\u0131\" \/><span class=\"wpcf7-list-item-label\">Kan hastal\u0131klar\u0131<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Z\u00fchrevi (cilt) hastal\u0131k\" \/><span class=\"wpcf7-list-item-label\">Z\u00fchrevi (cilt) hastal\u0131k<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Ast\u0131m, saman nezlesi\" \/><span class=\"wpcf7-list-item-label\">Ast\u0131m, saman nezlesi<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Akci\u011fer hastal\u0131klar\u0131\" \/><span class=\"wpcf7-list-item-label\">Akci\u011fer hastal\u0131klar\u0131<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Kanser te\u015fhisi\" \/><span class=\"wpcf7-list-item-label\">Kanser te\u015fhisi<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"vc_col-sm-12\" style=\"font-size: 24px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"other-medical-issues\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Bunlar\u0131n harici herhangi bir t\u0131bbi sorununuz var m\u0131?\" value=\"\" type=\"text\" name=\"other-medical-issues\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\n <!-- Bilgilerin do\u011frulu\u011fu onay\u0131 -->\n\t<div class=\"col-md-12\" style=\"font-size: 24px;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consent\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"consent[]\" value=\"Yukar\u0131daki bilgilerin do\u011frulu\u011funu kabul ediyorum.\" \/><span class=\"wpcf7-list-item-label\">Yukar\u0131daki bilgilerin do\u011frulu\u011funu kabul ediyorum.<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div style=\"margin-top:30px; font-size: 24px;\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"G\u00f6nder\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" 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