{"id":6655,"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\/pl\/form\/","title":{"rendered":"Hasta Kay\u0131t Formu"},"content":{"rendered":"[vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#000000&#8243; scene_position=&#8221;center&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221; column_padding_type=&#8221;default&#8221; gradient_type=&#8221;default&#8221; offset=&#8221;vc_hidden-sm vc_hidden-xs&#8221;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6627-o1\" lang=\"pl-PL\" dir=\"ltr\" data-wpcf7-id=\"6627\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/pl\/wp-json\/wp\/v2\/pages\/6655#wpcf7-f6627-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formularz kontaktowy\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"6627\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"pl_PL\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6627-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=\"Imi\u0119 i Nazwisko\" 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=\"Numer Paszportu:\" 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;\">Data przyjazdu na leczenie do Stambu\u0142u\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;\">Data wyjazdu ze Stambu\u0142u\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;\">Czy masz zwyczaj picia alkoholu? Jak cz\u0119sto?\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=\"Nie\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Nie<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Codziennie\" \/><span class=\"wpcf7-list-item-label\">Codziennie<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Co drugi dzie\u0144\" \/><span class=\"wpcf7-list-item-label\">Co drugi dzie\u0144<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"Raz w tygodniu\" \/><span class=\"wpcf7-list-item-label\">Raz w tygodniu<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-8\" value=\"Raz w miesi\u0105cu\" \/><span class=\"wpcf7-list-item-label\">Raz w miesi\u0105cu<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px; margin-top:20px;\">Czy zgrzytasz z\u0119bami?\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=\"Nie\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Nie<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-673\" value=\"Tak\" \/><span class=\"wpcf7-list-item-label\">Tak<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px; margin-top:20px;\">Czy masz alergi\u0119 na antybiotyki?\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=\"Nie\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Nie<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-674\" value=\"Tak\" \/><span class=\"wpcf7-list-item-label\">Tak<\/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=\"Czy aktualnie otrzymujesz leczenie?\" 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=\"Czy bierzesz leki?\" 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=\"Czy masz jakiekolwiek choroby lub histori\u0119 chor\u00f3b?\" 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=\"Choroby serca\" \/><span class=\"wpcf7-list-item-label\">Choroby serca<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Problemy z ci\u015bnieniem\" \/><span class=\"wpcf7-list-item-label\">Problemy z ci\u015bnieniem<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Rheumatyzm gor\u0105czkowy\" \/><span class=\"wpcf7-list-item-label\">Rheumatyzm gor\u0105czkowy<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Goiter (leki na tarczyc\u0119)\" \/><span class=\"wpcf7-list-item-label\">Goiter (leki na tarczyc\u0119)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Alergie (leki, jedzenie, itp.)\" \/><span class=\"wpcf7-list-item-label\">Alergie (leki, jedzenie, itp.)<\/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=\"Choroby nerek lub w\u0105troby\" \/><span class=\"wpcf7-list-item-label\">Choroby nerek lub w\u0105troby<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Zapalenie zatok\" \/><span class=\"wpcf7-list-item-label\">Zapalenie zatok<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Choroby zaka\u017ane (Hepatitis, AIDS itp.)\" \/><span class=\"wpcf7-list-item-label\">Choroby zaka\u017ane (Hepatitis, AIDS itp.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Cukrzyca\" \/><span class=\"wpcf7-list-item-label\">Cukrzyca<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Epilepsja (drgawki)\" \/><span class=\"wpcf7-list-item-label\">Epilepsja (drgawki)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Reumatyzm staw\u00f3w\" \/><span class=\"wpcf7-list-item-label\">Reumatyzm staw\u00f3w<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Choroby krwi\" \/><span class=\"wpcf7-list-item-label\">Choroby krwi<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Choroby sk\u00f3ry\" \/><span class=\"wpcf7-list-item-label\">Choroby sk\u00f3ry<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Astma, katar sienny\" \/><span class=\"wpcf7-list-item-label\">Astma, katar sienny<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Choroby p\u0142uc\" \/><span class=\"wpcf7-list-item-label\">Choroby p\u0142uc<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diseases[]\" value=\"Diagnoza raka\" \/><span class=\"wpcf7-list-item-label\">Diagnoza raka<\/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=\"Czy masz inne problemy zdrowotne?\" 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=\"Zgadzam si\u0119 na poprawno\u015b\u0107 powy\u017cszych informacji.\" \/><span class=\"wpcf7-list-item-label\">Zgadzam si\u0119 na poprawno\u015b\u0107 powy\u017cszych informacji.<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div style=\"margin-top:30px; font-size: 22px;\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Wy\u015blij\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#000000&#8243; scene_position=&#8221;center&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221; column_padding_type=&#8221;default&#8221; gradient_type=&#8221;default&#8221; offset=&#8221;vc_hidden-lg vc_hidden-md&#8221;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6641-o2\" lang=\"pl-PL\" dir=\"ltr\" data-wpcf7-id=\"6641\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/pl\/wp-json\/wp\/v2\/pages\/6655#wpcf7-f6641-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formularz kontaktowy\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"6641\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"pl_PL\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6641-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 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