{"id":6651,"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\/fr\/form\/","title":{"rendered":"Hasta Kay\u0131t Formu"},"content":{"rendered":"[vc_row type=\u00a0\u00bbfull_width_background\u00a0\u00bb full_screen_row_position=\u00a0\u00bbmiddle\u00a0\u00bb column_margin=\u00a0\u00bbdefault\u00a0\u00bb column_direction=\u00a0\u00bbdefault\u00a0\u00bb column_direction_tablet=\u00a0\u00bbdefault\u00a0\u00bb column_direction_phone=\u00a0\u00bbdefault\u00a0\u00bb bg_color=\u00a0\u00bb#000000&Prime; scene_position=\u00a0\u00bbcenter\u00a0\u00bb text_color=\u00a0\u00bbdark\u00a0\u00bb text_align=\u00a0\u00bbleft\u00a0\u00bb row_border_radius=\u00a0\u00bbnone\u00a0\u00bb row_border_radius_applies=\u00a0\u00bbbg\u00a0\u00bb overflow=\u00a0\u00bbvisible\u00a0\u00bb overlay_strength=\u00a0\u00bb0.3&Prime; 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width=\u00a0\u00bb1\/1&Prime; tablet_width_inherit=\u00a0\u00bbdefault\u00a0\u00bb animation_type=\u00a0\u00bbdefault\u00a0\u00bb bg_image_animation=\u00a0\u00bbnone\u00a0\u00bb border_type=\u00a0\u00bbsimple\u00a0\u00bb column_border_width=\u00a0\u00bbnone\u00a0\u00bb column_border_style=\u00a0\u00bbsolid\u00a0\u00bb column_padding_type=\u00a0\u00bbdefault\u00a0\u00bb gradient_type=\u00a0\u00bbdefault\u00a0\u00bb offset=\u00a0\u00bbvc_hidden-sm vc_hidden-xs\u00a0\u00bb]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6623-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"6623\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/6651#wpcf7-f6623-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"6623\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6623-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=\"Nom et Pr\u00e9nom\" 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=\"Num\u00e9ro de Passeport:\" 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;\">Date d'arriv\u00e9e pour traitement \u00e0 Istanbul\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;\">Date de d\u00e9part d'Istanbul\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;\">Avez-vous l'habitude de consommer de l'alcool ? Quelle est la fr\u00e9quence ?\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=\"Non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Tous les jours\" \/><span class=\"wpcf7-list-item-label\">Tous les jours<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Tous les deux jours\" \/><span class=\"wpcf7-list-item-label\">Tous les deux jours<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Une fois par semaine\" \/><span class=\"wpcf7-list-item-label\">Une fois par semaine<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-8\" value=\"Une fois par mois\" \/><span class=\"wpcf7-list-item-label\">Une fois par mois<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px; margin-top:20px;\">Grincez-vous des dents ?\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=\"Non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-673\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px; margin-top:20px;\">Avez-vous une allergie aux antibiotiques ?\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=\"Non\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-674\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/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=\"Suivez-vous un traitement actuellement ?\" 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=\"Prenez-vous des m\u00e9dicaments ?\" 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=\"Avez-vous une maladie ou un ant\u00e9c\u00e9dent m\u00e9dical ?\" 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=\"Maladies cardiaques\" \/><span class=\"wpcf7-list-item-label\">Maladies cardiaques<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Probl\u00e8mes de tension art\u00e9rielle\" \/><span class=\"wpcf7-list-item-label\">Probl\u00e8mes de tension art\u00e9rielle<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Rhumatisme articulaire aigu\" \/><span class=\"wpcf7-list-item-label\">Rhumatisme articulaire aigu<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Goitre (m\u00e9dicaments pour la thyro\u00efde)\" \/><span class=\"wpcf7-list-item-label\">Goitre (m\u00e9dicaments pour la thyro\u00efde)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Allergies (m\u00e9dicaments, aliments, etc.)\" \/><span class=\"wpcf7-list-item-label\">Allergies (m\u00e9dicaments, aliments, etc.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"H\u00e9patite\" \/><span class=\"wpcf7-list-item-label\">H\u00e9patite<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Troubles r\u00e9naux ou h\u00e9patiques\" \/><span class=\"wpcf7-list-item-label\">Troubles r\u00e9naux ou h\u00e9patiques<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Sinusite\" \/><span class=\"wpcf7-list-item-label\">Sinusite<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Maladies infectieuses (h\u00e9patite, sida, etc.)\" \/><span class=\"wpcf7-list-item-label\">Maladies infectieuses (h\u00e9patite, sida, etc.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Diab\u00e8te\" \/><span class=\"wpcf7-list-item-label\">Diab\u00e8te<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u00c9pilepsie (crises)\" \/><span class=\"wpcf7-list-item-label\">\u00c9pilepsie (crises)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Rhumatisme articulaire\" \/><span class=\"wpcf7-list-item-label\">Rhumatisme articulaire<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Troubles sanguins\" \/><span class=\"wpcf7-list-item-label\">Troubles sanguins<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Maladies de la peau\" \/><span class=\"wpcf7-list-item-label\">Maladies de la peau<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Asthme, rhume des foins\" \/><span class=\"wpcf7-list-item-label\">Asthme, rhume des foins<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Maladies pulmonaires\" \/><span class=\"wpcf7-list-item-label\">Maladies pulmonaires<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Diagnostic de cancer\" \/><span class=\"wpcf7-list-item-label\">Diagnostic de cancer<\/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\" 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aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row][vc_row type=\u00a0\u00bbfull_width_background\u00a0\u00bb full_screen_row_position=\u00a0\u00bbmiddle\u00a0\u00bb column_margin=\u00a0\u00bbdefault\u00a0\u00bb column_direction=\u00a0\u00bbdefault\u00a0\u00bb column_direction_tablet=\u00a0\u00bbdefault\u00a0\u00bb column_direction_phone=\u00a0\u00bbdefault\u00a0\u00bb bg_color=\u00a0\u00bb#000000&Prime; scene_position=\u00a0\u00bbcenter\u00a0\u00bb text_color=\u00a0\u00bbdark\u00a0\u00bb text_align=\u00a0\u00bbleft\u00a0\u00bb row_border_radius=\u00a0\u00bbnone\u00a0\u00bb row_border_radius_applies=\u00a0\u00bbbg\u00a0\u00bb overflow=\u00a0\u00bbvisible\u00a0\u00bb overlay_strength=\u00a0\u00bb0.3&Prime; gradient_direction=\u00a0\u00bbleft_to_right\u00a0\u00bb shape_divider_position=\u00a0\u00bbbottom\u00a0\u00bb bg_image_animation=\u00a0\u00bbnone\u00a0\u00bb gradient_type=\u00a0\u00bbdefault\u00a0\u00bb shape_type=\u00a0\u00bb\u00a0\u00bb][vc_column 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tablet_width_inherit=\u00a0\u00bbdefault\u00a0\u00bb animation_type=\u00a0\u00bbdefault\u00a0\u00bb bg_image_animation=\u00a0\u00bbnone\u00a0\u00bb border_type=\u00a0\u00bbsimple\u00a0\u00bb column_border_width=\u00a0\u00bbnone\u00a0\u00bb column_border_style=\u00a0\u00bbsolid\u00a0\u00bb column_padding_type=\u00a0\u00bbdefault\u00a0\u00bb gradient_type=\u00a0\u00bbdefault\u00a0\u00bb offset=\u00a0\u00bbvc_hidden-lg vc_hidden-md\u00a0\u00bb]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6637-o2\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"6637\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/6651#wpcf7-f6637-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"6637\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6637-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 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