{"id":6657,"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\/ru\/form\/","title":{"rendered":"Hasta Kay\u0131t Formu"},"content":{"rendered":"[vc_row type=&#187;full_width_background&#187; full_screen_row_position=&#187;middle&#187; column_margin=&#187;default&#187; column_direction=&#187;default&#187; column_direction_tablet=&#187;default&#187; column_direction_phone=&#187;default&#187; bg_color=&#187;#000000&#8243; scene_position=&#187;center&#187; text_color=&#187;dark&#187; text_align=&#187;left&#187; row_border_radius=&#187;none&#187; row_border_radius_applies=&#187;bg&#187; overflow=&#187;visible&#187; overlay_strength=&#187;0.3&#8243; gradient_direction=&#187;left_to_right&#187; shape_divider_position=&#187;bottom&#187; 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22px;\">\u0414\u0430\u0442\u0430 \u043e\u0442\u044a\u0435\u0437\u0434\u0430 \u0438\u0437 \u0421\u0442\u0430\u043c\u0431\u0443\u043b\u0430\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;\">\u0415\u0441\u0442\u044c \u043b\u0438 \u0443 \u0432\u0430\u0441 \u043f\u0440\u0438\u0432\u044b\u0447\u043a\u0430 \u0443\u043f\u043e\u0442\u0440\u0435\u0431\u043b\u044f\u0442\u044c \u0430\u043b\u043a\u043e\u0433\u043e\u043b\u044c? \u041a\u0430\u043a \u0447\u0430\u0441\u0442\u043e?\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=\"\u041d\u0435\u0442\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u041d\u0435\u0442<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"\u041a\u0430\u0436\u0434\u044b\u0439 \u0434\u0435\u043d\u044c\" \/><span class=\"wpcf7-list-item-label\">\u041a\u0430\u0436\u0434\u044b\u0439 \u0434\u0435\u043d\u044c<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"\u041a\u0430\u0436\u0434\u044b\u0435 \u0434\u0432\u0430 \u0434\u043d\u044f\" \/><span class=\"wpcf7-list-item-label\">\u041a\u0430\u0436\u0434\u044b\u0435 \u0434\u0432\u0430 \u0434\u043d\u044f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-8\" value=\"\u0420\u0430\u0437 \u0432 \u043d\u0435\u0434\u0435\u043b\u044e\" \/><span class=\"wpcf7-list-item-label\">\u0420\u0430\u0437 \u0432 \u043d\u0435\u0434\u0435\u043b\u044e<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-8\" value=\"\u0420\u0430\u0437 \u0432 \u043c\u0435\u0441\u044f\u0446\" \/><span class=\"wpcf7-list-item-label\">\u0420\u0430\u0437 \u0432 \u043c\u0435\u0441\u044f\u0446<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p style=\"color:white; font-size: 22px; margin-top:20px;\">\u0421\u043a\u0440\u0438\u043f\u0438\u0442\u0435 \u043b\u0438 \u0432\u044b \u0437\u0443\u0431\u0430\u043c\u0438?\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=\"\u041d\u0435\u0442\" 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name=\"diseases[]\" value=\"\u0410\u043b\u043b\u0435\u0440\u0433\u0438\u0438 (\u043b\u0435\u043a\u0430\u0440\u0441\u0442\u0432\u0430, \u043f\u0440\u043e\u0434\u0443\u043a\u0442\u044b \u043f\u0438\u0442\u0430\u043d\u0438\u044f \u0438 \u0442. \u0434.)\" \/><span class=\"wpcf7-list-item-label\">\u0410\u043b\u043b\u0435\u0440\u0433\u0438\u0438 (\u043b\u0435\u043a\u0430\u0440\u0441\u0442\u0432\u0430, \u043f\u0440\u043e\u0434\u0443\u043a\u0442\u044b \u043f\u0438\u0442\u0430\u043d\u0438\u044f \u0438 \u0442. \u0434.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0413\u0435\u043f\u0430\u0442\u0438\u0442\" \/><span class=\"wpcf7-list-item-label\">\u0413\u0435\u043f\u0430\u0442\u0438\u0442<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0417\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f \u043f\u043e\u0447\u0435\u043a \u0438\u043b\u0438 \u043f\u0435\u0447\u0435\u043d\u0438\" 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\u0434.)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0414\u0438\u0430\u0431\u0435\u0442\" \/><span class=\"wpcf7-list-item-label\">\u0414\u0438\u0430\u0431\u0435\u0442<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u042d\u043f\u0438\u043b\u0435\u043f\u0441\u0438\u044f (\u0441\u0443\u0434\u043e\u0440\u043e\u0433\u0438)\" \/><span class=\"wpcf7-list-item-label\">\u042d\u043f\u0438\u043b\u0435\u043f\u0441\u0438\u044f (\u0441\u0443\u0434\u043e\u0440\u043e\u0433\u0438)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0420\u0435\u0432\u043c\u0430\u0442\u0438\u0437\u043c \u0441\u0443\u0441\u0442\u0430\u0432\u043e\u0432\" \/><span class=\"wpcf7-list-item-label\">\u0420\u0435\u0432\u043c\u0430\u0442\u0438\u0437\u043c \u0441\u0443\u0441\u0442\u0430\u0432\u043e\u0432<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0417\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f \u043a\u0440\u043e\u0432\u0438\" \/><span class=\"wpcf7-list-item-label\">\u0417\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f \u043a\u0440\u043e\u0432\u0438<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u041a\u043e\u0436\u043d\u044b\u0435 \u0437\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f\" \/><span class=\"wpcf7-list-item-label\">\u041a\u043e\u0436\u043d\u044b\u0435 \u0437\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0410\u0441\u0442\u043c\u0430, \u0441\u0435\u043d\u043d\u0430\u044f \u043b\u0438\u0445\u043e\u0440\u0430\u0434\u043a\u0430\" \/><span class=\"wpcf7-list-item-label\">\u0410\u0441\u0442\u043c\u0430, \u0441\u0435\u043d\u043d\u0430\u044f \u043b\u0438\u0445\u043e\u0440\u0430\u0434\u043a\u0430<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0417\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f \u043b\u0435\u0433\u043a\u0438\u0445\" \/><span class=\"wpcf7-list-item-label\">\u0417\u0430\u0431\u043e\u043b\u0435\u0432\u0430\u043d\u0438\u044f \u043b\u0435\u0433\u043a\u0438\u0445<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diseases[]\" value=\"\u0414\u0438\u0430\u0433\u043d\u043e\u0437 \u0440\u0430\u043a\" \/><span class=\"wpcf7-list-item-label\">\u0414\u0438\u0430\u0433\u043d\u043e\u0437 \u0440\u0430\u043a<\/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=\"\u0415\u0441\u0442\u044c \u043b\u0438 \u0443 \u0432\u0430\u0441 \u0434\u0440\u0443\u0433\u0438\u0435 \u043c\u0435\u0434\u0438\u0446\u0438\u043d\u0441\u043a\u0438\u0435 \u043f\u0440\u043e\u0431\u043b\u0435\u043c\u044b?\" 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=\"\u042f \u0441\u043e\u0433\u043b\u0430\u0441\u0435\u043d \u0441 \u0442\u043e\u0447\u043d\u043e\u0441\u0442\u044c\u044e \u0432\u044b\u0448\u0435\u0443\u043a\u0430\u0437\u0430\u043d\u043d\u043e\u0439 \u0438\u043d\u0444\u043e\u0440\u043c\u0430\u0446\u0438\u0438.\" \/><span class=\"wpcf7-list-item-label\">\u042f \u0441\u043e\u0433\u043b\u0430\u0441\u0435\u043d \u0441 \u0442\u043e\u0447\u043d\u043e\u0441\u0442\u044c\u044e \u0432\u044b\u0448\u0435\u0443\u043a\u0430\u0437\u0430\u043d\u043d\u043e\u0439 \u0438\u043d\u0444\u043e\u0440\u043c\u0430\u0446\u0438\u0438.<\/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=\"\u041e\u0442\u043f\u0440\u0430\u0432\u0438\u0442\u044c\" \/>\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=&#187;full_width_background&#187; full_screen_row_position=&#187;middle&#187; column_margin=&#187;default&#187; column_direction=&#187;default&#187; column_direction_tablet=&#187;default&#187; column_direction_phone=&#187;default&#187; bg_color=&#187;#000000&#8243; scene_position=&#187;center&#187; text_color=&#187;dark&#187; text_align=&#187;left&#187; row_border_radius=&#187;none&#187; row_border_radius_applies=&#187;bg&#187; overflow=&#187;visible&#187; overlay_strength=&#187;0.3&#8243; gradient_direction=&#187;left_to_right&#187; shape_divider_position=&#187;bottom&#187; bg_image_animation=&#187;none&#187; gradient_type=&#187;default&#187; shape_type=&#187;&#187;][vc_column column_padding=&#187;no-extra-padding&#187; column_padding_tablet=&#187;inherit&#187; column_padding_phone=&#187;inherit&#187; column_padding_position=&#187;all&#187; column_element_direction_desktop=&#187;default&#187; column_element_spacing=&#187;default&#187; desktop_text_alignment=&#187;default&#187; tablet_text_alignment=&#187;default&#187; phone_text_alignment=&#187;default&#187; background_color_opacity=&#187;1&#8243; background_hover_color_opacity=&#187;1&#8243; column_backdrop_filter=&#187;none&#187; column_shadow=&#187;none&#187; column_border_radius=&#187;none&#187; column_link_target=&#187;_self&#187; column_position=&#187;default&#187; gradient_direction=&#187;left_to_right&#187; overlay_strength=&#187;0.3&#8243; width=&#187;1\/1&#8243; tablet_width_inherit=&#187;default&#187; animation_type=&#187;default&#187; bg_image_animation=&#187;none&#187; border_type=&#187;simple&#187; column_border_width=&#187;none&#187; column_border_style=&#187;solid&#187; column_padding_type=&#187;default&#187; gradient_type=&#187;default&#187; offset=&#187;vc_hidden-lg vc_hidden-md&#187;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f6643-o2\" lang=\"ru-RU\" dir=\"ltr\" data-wpcf7-id=\"6643\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/ru\/wp-json\/wp\/v2\/pages\/6657#wpcf7-f6643-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"\u041a\u043e\u043d\u0442\u0430\u043a\u0442\u043d\u0430\u044f \u0444\u043e\u0440\u043c\u0430\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"6643\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ru_RU\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f6643-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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