{"id":1609,"date":"2025-07-02T16:05:35","date_gmt":"2025-07-02T14:05:35","guid":{"rendered":"https:\/\/dentique.be\/new-patients\/"},"modified":"2026-10-15T23:18:55","modified_gmt":"2026-10-15T21:18:55","slug":"new-patients","status":"publish","type":"page","link":"https:\/\/dentique.be\/en\/new-patients\/","title":{"rendered":"New patients"},"content":{"rendered":"\n<p class=\"has-text-align-center wp-block-paragraph\">Would you like to register as a new patient? If so, please fill out our <strong>application form <\/strong>.<\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">Due to high demand, we are currently working with a <strong>waiting list<\/strong>. After your application is registered, you will receive a confirmation email. Depending on availability in our schedules, we will then contact you.<\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\">We look forward to welcoming you to our practice.<\/p>\n\n\n\n<div style=\"height:var(--wp--preset--spacing--60)\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1606 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1606\" data-uid=\"6af65974396eb\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1606\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1606 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1606\"\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6af65974396eb\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_6af65974396eb\" id=\"forminator-field-first-name-1_6af65974396eb-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_6af65974396eb\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_6af65974396eb\" id=\"forminator-field-last-name-1_6af65974396eb-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_6af65974396eb\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6af65974396eb\" id=\"forminator-field-email-1_6af65974396eb-label\" class=\"forminator-label\">E-mail <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6af65974396eb\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6af65974396eb\" id=\"forminator-field-phone-1_6af65974396eb-label\" class=\"forminator-label\">Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6af65974396eb\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12  adres-wrapper\"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6af65974396eb\" id=\"forminator-field-address-1-street_address_6af65974396eb-label\" class=\"forminator-label\">Street<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6af65974396eb\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6af65974396eb\" id=\"forminator-field-address-1-address_line_6af65974396eb-label\" class=\"forminator-label\">Number<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6af65974396eb\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12  adres-wrapper\"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_6af65974396eb\" id=\"forminator-field-address-2-city_6af65974396eb-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_6af65974396eb\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_6af65974396eb\" id=\"forminator-field-address-2-zip_6af65974396eb-label\" class=\"forminator-label\">Zip code<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_6af65974396eb\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6af65974396eb\" id=\"forminator-field-date-1-picker_6af65974396eb-label\" class=\"forminator-label\">Date of birth <span class=\"forminator-required\">*<\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose date\" id=\"forminator-field-date-1-picker_6af65974396eb\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6af65974396eb\" id=\"forminator-field-text-2_6af65974396eb-label\" class=\"forminator-label\">National register number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"XX.XX.XX-XXX.XX\" id=\"forminator-field-text-2_6af65974396eb\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6af65974396eb\" id=\"forminator-field-text-1_6af65974396eb-label\" class=\"forminator-label\">Supplementary dental insurance<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6af65974396eb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1606__field--select-1_6af65974396eb\" id=\"forminator-form-1606__field--select-1_6af65974396eb-label\" class=\"forminator-label\">Reason for your appointment <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-1606__field--select-1_6af65974396eb\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Selecteer een optie\" data-search=\"false\" data-search-placeholder=\"Selecteer een optie\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1606__field--select-1_6af65974396eb-label\"><option value=\"\"  >Selecteer een optie<\/option><option value=\"Controle\"  data-calculation=\"0\">Reason for your appointment<\/option><option value=\"Pain complaint\"  data-calculation=\"0\">Check-up<\/option><option value=\"Bleaching\"  data-calculation=\"0\">Bleaching<\/option><option value=\"Prosthesis\"  data-calculation=\"0\">Prosthesis<\/option><option value=\"Crown and bridgework or veneers\"  data-calculation=\"0\">Crown and bridgework or veneers<\/option><option value=\"Implant\"  data-calculation=\"0\">Implant<\/option><option value=\"Gum surgery\"  data-calculation=\"0\">Gum surgery<\/option><option value=\"Extraction\"  data-calculation=\"0\">Extraction<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-1606__field--select-1_6af65974396eb\" name=\"custom-select-1\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1606__field--select-3_6af65974396eb\" id=\"forminator-form-1606__field--select-3_6af65974396eb-label\" class=\"forminator-label\">Would you like to schedule an appointment with one of our dentists listed below? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-1606__field--select-3_6af65974396eb\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Selecteer een optie\" data-search=\"false\" data-search-placeholder=\"Selecteer een optie\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1606__field--select-3_6af65974396eb-label\"><option value=\"\"  >Selecteer een optie<\/option><option value=\"No specific preference\"  data-calculation=\"0\">No specific preference<\/option><option value=\"Rima Nassar (Periodontology\/Implantology)\"  data-calculation=\"0\">Rima Nassar (Periodontology\/Implantology)<\/option><option value=\"Louise Lietaer (Restorative\/Aesthetic Dentistry)\"  data-calculation=\"0\">Louise Lietaer (Restorative\/Aesthetic Dentistry)<\/option><option value=\"Judith Peirelinck (General Dentristry)\"  data-calculation=\"0\">Judith Peirelinck (General Dentristry)<\/option><option value=\"Emilie Michielsens (General Dentristry)\"  data-calculation=\"0\">Emilie Michielsens (General Dentristry)<\/option><option value=\"Ine Van Slagmolen (General Dentristry)\"  data-calculation=\"0\">Ine Van Slagmolen (General Dentristry)<\/option><option value=\"Ben-Van-Aelst-(Endodontist)\"  data-calculation=\"0\">Ben Van Aelst (Endodontist)<\/option><option value=\"Dr. Politis (Oral and Maxillofacial Surgeon)\"  data-calculation=\"0\">Dr. Politis (Oral and Maxillofacial Surgeon)<\/option><option value=\"Katrien Blancke (Restorative\/Aesthetic Dentistry)\"  data-calculation=\"0\">Katrien Blancke (Restorative\/Aesthetic Dentistry)<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-1606__field--select-3_6af65974396eb\" name=\"custom-select-3\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-1606__field--select-2_6af65974396eb\" id=\"forminator-form-1606__field--select-2_6af65974396eb-label\" class=\"forminator-label\">How did you find out about the practice? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-1606__field--select-2_6af65974396eb\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Selecteer een optie\" data-search=\"false\" data-search-placeholder=\"Selecteer een optie\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1606__field--select-2_6af65974396eb-label\"><option value=\"\"  >Selecteer een optie<\/option><option value=\"Via-the-internet\"  data-calculation=\"0\">Via the internet<\/option><option value=\"Through-friends-or-family\"  data-calculation=\"0\">Through friends or family<\/option><option value=\"Referred-by-a-(dentist)-doctor\"  data-calculation=\"0\">Referred by a (dentist) doctor<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-1606__field--select-2_6af65974396eb\" name=\"custom-select-2\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6af65974396eb\" id=\"forminator-field-upload-1_6af65974396eb-label\" class=\"forminator-label\">Upload your referral letter<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_6af65974396eb\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_6af65974396eb\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.x-wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages,image\/jpeg,image\/gif,image\/png,image\/bmp,image\/tiff,image\/webp,image\/avif,image\/x-icon,image\/heic,image\/heif,image\/heic-sequence,image\/heif-sequence,video\/x-ms-asf,video\/x-ms-wmv,video\/x-ms-wmx,video\/x-ms-wm,video\/avi,video\/divx,video\/x-flv,video\/quicktime,video\/mpeg,video\/mp4,video\/ogg,video\/webm,video\/x-matroska,video\/3gpp,video\/3gpp2,text\/plain,text\/csv,text\/tab-separated-values,text\/calendar,text\/richtext,text\/vtt,audio\/mpeg,audio\/aac,audio\/x-realaudio,audio\/wav,audio\/ogg,audio\/flac,audio\/midi,audio\/x-ms-wma,audio\/x-ms-wax,audio\/x-matroska,application\/rtf,application\/pdf,application\/java,application\/x-tar,application\/zip,application\/x-gzip,application\/x-7z-compressed,application\/octet-stream,application\/msword,application\/vnd.ms-powerpoint,application\/vnd.ms-write,application\/vnd.ms-excel,application\/vnd.ms-access,application\/vnd.ms-project,application\/vnd.openxmlformats-officedocument.wordprocessingml.document,application\/vnd.ms-word.document.macroEnabled.12,application\/vnd.openxmlformats-officedocument.wordprocessingml.template,application\/vnd.ms-word.template.macroEnabled.12,application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet,application\/vnd.ms-excel.sheet.macroEnabled.12,application\/vnd.ms-excel.sheet.binary.macroEnabled.12,application\/vnd.openxmlformats-officedocument.spreadsheetml.template,application\/vnd.ms-excel.template.macroEnabled.12,application\/vnd.ms-excel.addin.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.presentation,application\/vnd.ms-powerpoint.presentation.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.slideshow,application\/vnd.ms-powerpoint.slideshow.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.template,application\/vnd.ms-powerpoint.template.macroEnabled.12,application\/vnd.ms-powerpoint.addin.macroEnabled.12,application\/vnd.openxmlformats-officedocument.presentationml.slide,application\/vnd.ms-powerpoint.slide.macroEnabled.12,application\/onenote,application\/oxps,application\/vnd.ms-xpsdocument,application\/vnd.oasis.opendocument.text,application\/vnd.oasis.opendocument.presentation,application\/vnd.oasis.opendocument.spreadsheet,application\/vnd.oasis.opendocument.graphics,application\/vnd.oasis.opendocument.chart,application\/vnd.oasis.opendocument.database,application\/vnd.oasis.opendocument.formula,application\/wordperfect,application\/vnd.apple.keynote,application\/vnd.apple.numbers,application\/vnd.apple.pages\" tabindex=\"-1\"><button id=\"forminator-field-upload-1_6af65974396eb_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_6af65974396eb\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6af65974396eb-label\"><span id=\"forminator-radiogroup-radio-1-6af65974396eb-label\" class=\"forminator-label\">Would you like to receive a reminder when it\u2019s time for your next check-up? This reminder will be sent by email.<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6af65974396eb\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"Yes\" id=\"forminator-field-radio-1-1-6af65974396eb\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6af65974396eb\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"No\" id=\"forminator-field-radio-1-2-6af65974396eb\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6af65974396eb-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6af65974396eb-label\" class=\"forminator-label\">Do you have (or have you had) a medical condition? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-2-1-6af65974396eb-label\" for=\"forminator-field-checkbox-2-1-6af65974396eb\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"No\" id=\"forminator-field-checkbox-2-1-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-1-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6af65974396eb-label\" for=\"forminator-field-checkbox-2-2-6af65974396eb\" class=\"forminator-checkbox\" title=\"Osteoporosis\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Osteoporosis\" id=\"forminator-field-checkbox-2-2-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-2-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Osteoporosis<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6af65974396eb-label\" for=\"forminator-field-checkbox-2-3-6af65974396eb\" class=\"forminator-checkbox\" title=\"Heart problems\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Heart-problems\" id=\"forminator-field-checkbox-2-3-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-3-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart problems<\/span><\/label><label id=\"forminator-field-checkbox-2-4-6af65974396eb-label\" for=\"forminator-field-checkbox-2-4-6af65974396eb\" class=\"forminator-checkbox\" title=\"Heart rhythm disorders\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Heart-rhythm-disorders\" id=\"forminator-field-checkbox-2-4-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-4-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart rhythm disorders<\/span><\/label><label id=\"forminator-field-checkbox-2-5-6af65974396eb-label\" for=\"forminator-field-checkbox-2-5-6af65974396eb\" class=\"forminator-checkbox\" title=\"High blood pressure\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"High-blood-pressure\" id=\"forminator-field-checkbox-2-5-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-5-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High blood pressure<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6af65974396eb-label\" for=\"forminator-field-checkbox-2-6-6af65974396eb\" class=\"forminator-checkbox\" title=\"Stroke or brain hemorrhage\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Stroke-or-brain-hemorrhage\" id=\"forminator-field-checkbox-2-6-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-6-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Stroke or brain hemorrhage<\/span><\/label><label id=\"forminator-field-checkbox-2-7-6af65974396eb-label\" for=\"forminator-field-checkbox-2-7-6af65974396eb\" class=\"forminator-checkbox\" title=\"Diabetes\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Diabetes\" id=\"forminator-field-checkbox-2-7-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-7-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes<\/span><\/label><label id=\"forminator-field-checkbox-2-8-6af65974396eb-label\" for=\"forminator-field-checkbox-2-8-6af65974396eb\" class=\"forminator-checkbox\" title=\"Asthma\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Asthma\" id=\"forminator-field-checkbox-2-8-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-8-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Asthma<\/span><\/label><label id=\"forminator-field-checkbox-2-9-6af65974396eb-label\" for=\"forminator-field-checkbox-2-9-6af65974396eb\" class=\"forminator-checkbox\" title=\"Epilepsy\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Epilepsy\" id=\"forminator-field-checkbox-2-9-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-9-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Epilepsy<\/span><\/label><label id=\"forminator-field-checkbox-2-10-6af65974396eb-label\" for=\"forminator-field-checkbox-2-10-6af65974396eb\" class=\"forminator-checkbox\" title=\"Thyroid problems\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Thyroid-problems\" id=\"forminator-field-checkbox-2-10-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-10-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thyroid problems<\/span><\/label><label id=\"forminator-field-checkbox-2-11-6af65974396eb-label\" for=\"forminator-field-checkbox-2-11-6af65974396eb\" class=\"forminator-checkbox\" title=\"Stomach or intestinal problems\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Stomach-or-intestinal-problems\" id=\"forminator-field-checkbox-2-11-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-11-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Stomach or intestinal problems<\/span><\/label><label id=\"forminator-field-checkbox-2-12-6af65974396eb-label\" for=\"forminator-field-checkbox-2-12-6af65974396eb\" class=\"forminator-checkbox\" title=\"Liver problems\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Liver-problems\" id=\"forminator-field-checkbox-2-12-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-12-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Liver problems<\/span><\/label><label id=\"forminator-field-checkbox-2-13-6af65974396eb-label\" for=\"forminator-field-checkbox-2-13-6af65974396eb\" class=\"forminator-checkbox\" title=\"Kidney problems\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Kidney-problems\" id=\"forminator-field-checkbox-2-13-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-13-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kidney problems<\/span><\/label><label id=\"forminator-field-checkbox-2-14-6af65974396eb-label\" for=\"forminator-field-checkbox-2-14-6af65974396eb\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Cancer\" id=\"forminator-field-checkbox-2-14-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-2-14-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-field-checkbox-2-14-6af65974396eb\" name=\"custom-checkbox-2\" aria-labelledby=\"forminator-field-checkbox-2-14-6af65974396eb-label\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6af65974396eb\" id=\"forminator-field-text-6_6af65974396eb-label\" class=\"forminator-label\">Do you take any medication? If yes, which ones and for what purpose?<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_6af65974396eb\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6af65974396eb-label\"><span id=\"forminator-radiogroup-radio-2-6af65974396eb-label\" class=\"forminator-label\">Are you being treated, or have you been treated, for osteoporosis with bisphosphonates? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6af65974396eb\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"Yes\" id=\"forminator-field-radio-2-1-6af65974396eb\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6af65974396eb\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"No\" id=\"forminator-field-radio-2-2-6af65974396eb\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6af65974396eb-label\"><span id=\"forminator-radiogroup-radio-3-6af65974396eb-label\" class=\"forminator-label\">Do you have a blood clotting disorder? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6af65974396eb\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"Yes\" id=\"forminator-field-radio-3-1-6af65974396eb\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6af65974396eb\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"No\" id=\"forminator-field-radio-3-2-6af65974396eb\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6af65974396eb-label\"><span id=\"forminator-radiogroup-radio-4-6af65974396eb-label\" class=\"forminator-label\">Have you received radiation treatment to the head and neck area due to cancer? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6af65974396eb\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"Yes\" id=\"forminator-field-radio-4-1-6af65974396eb\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6af65974396eb\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"No\" id=\"forminator-field-radio-4-2-6af65974396eb\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-6\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-6-6af65974396eb-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-6af65974396eb-label\" class=\"forminator-label\">Are you allergic to any of the following products? If yes, please indicate below. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-6-1-6af65974396eb-label\" for=\"forminator-field-checkbox-6-1-6af65974396eb\" class=\"forminator-checkbox\" title=\"Penicillin\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Penicillin\" id=\"forminator-field-checkbox-6-1-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-6-1-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Penicillin<\/span><\/label><label id=\"forminator-field-checkbox-6-2-6af65974396eb-label\" for=\"forminator-field-checkbox-6-2-6af65974396eb\" class=\"forminator-checkbox\" title=\"Latex\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Latex\" id=\"forminator-field-checkbox-6-2-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-6-2-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Latex<\/span><\/label><label id=\"forminator-field-checkbox-6-3-6af65974396eb-label\" for=\"forminator-field-checkbox-6-3-6af65974396eb\" class=\"forminator-checkbox\" title=\"No allergies\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"No allergies\" id=\"forminator-field-checkbox-6-3-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-6-3-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No allergies<\/span><\/label><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-field-checkbox-6-3-6af65974396eb\" name=\"custom-checkbox-6\" aria-labelledby=\"forminator-field-checkbox-6-3-6af65974396eb-label\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6af65974396eb-label\"><span id=\"forminator-radiogroup-radio-5-6af65974396eb-label\" class=\"forminator-label\">Do you have a pacemaker? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6af65974396eb\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"Yes\" id=\"forminator-field-radio-5-1-6af65974396eb\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6af65974396eb\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"No\" id=\"forminator-field-radio-5-2-6af65974396eb\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6af65974396eb-label\"><span id=\"forminator-radiogroup-radio-6-6af65974396eb-label\" class=\"forminator-label\">Do you have a knee or hip prosthesis, or an artificial heart valve? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6af65974396eb\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-6\" value=\"Yes\" id=\"forminator-field-radio-6-1-6af65974396eb\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6af65974396eb\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-6\" value=\"No\" id=\"forminator-field-radio-6-2-6af65974396eb\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-9\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-9-6af65974396eb-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9-6af65974396eb-label\" class=\"forminator-label\">Do you have a contagious disease? If yes, please indicate below. <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-9-1-6af65974396eb-label\" for=\"forminator-field-checkbox-9-1-6af65974396eb\" class=\"forminator-checkbox\" title=\"Hepatitis\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Hepatitis\" id=\"forminator-field-checkbox-9-1-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-9-1-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hepatitis<\/span><\/label><label id=\"forminator-field-checkbox-9-2-6af65974396eb-label\" for=\"forminator-field-checkbox-9-2-6af65974396eb\" class=\"forminator-checkbox\" title=\"HIV\/AIDS\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"HIV-AIDS\" id=\"forminator-field-checkbox-9-2-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-9-2-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">HIV\/AIDS<\/span><\/label><label id=\"forminator-field-checkbox-9-3-6af65974396eb-label\" for=\"forminator-field-checkbox-9-3-6af65974396eb\" class=\"forminator-checkbox\" title=\"Tuberculosis\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"Tuberculosis\" id=\"forminator-field-checkbox-9-3-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-9-3-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tuberculosis<\/span><\/label><label id=\"forminator-field-checkbox-9-4-6af65974396eb-label\" for=\"forminator-field-checkbox-9-4-6af65974396eb\" class=\"forminator-checkbox\" title=\"No contagious disease\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"No contagious disease\" id=\"forminator-field-checkbox-9-4-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-9-4-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No contagious disease<\/span><\/label><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-field-checkbox-9-4-6af65974396eb\" name=\"custom-checkbox-9\" aria-labelledby=\"forminator-field-checkbox-9-4-6af65974396eb-label\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-10\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-10-6af65974396eb-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-10-6af65974396eb-label\" class=\"forminator-label\">Do you smoke? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-10-1-6af65974396eb-label\" for=\"forminator-field-checkbox-10-1-6af65974396eb\" class=\"forminator-checkbox\" title=\"No\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"No\" id=\"forminator-field-checkbox-10-1-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-10-1-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">No<\/span><\/label><label id=\"forminator-field-checkbox-10-2-6af65974396eb-label\" for=\"forminator-field-checkbox-10-2-6af65974396eb\" class=\"forminator-checkbox\" title=\"Occasionally\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"Occasionally\" id=\"forminator-field-checkbox-10-2-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-10-2-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Occasionally<\/span><\/label><label id=\"forminator-field-checkbox-10-3-6af65974396eb-label\" for=\"forminator-field-checkbox-10-3-6af65974396eb\" class=\"forminator-checkbox\" title=\"&lt; 10 cigarettes\/day\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"&lt;-10-cigarettes-day\" id=\"forminator-field-checkbox-10-3-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-10-3-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">&lt; 10 cigarettes\/day<\/span><\/label><label id=\"forminator-field-checkbox-10-4-6af65974396eb-label\" for=\"forminator-field-checkbox-10-4-6af65974396eb\" class=\"forminator-checkbox\" title=\"&gt; 10 cigarettes\/day\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"&gt;-10-cigarettes-day\" id=\"forminator-field-checkbox-10-4-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-10-4-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">&gt; 10 cigarettes\/day<\/span><\/label><label id=\"forminator-field-checkbox-10-5-6af65974396eb-label\" for=\"forminator-field-checkbox-10-5-6af65974396eb\" class=\"forminator-checkbox\" title=\"Electronic cigarette\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"Electronic-cigarette\" id=\"forminator-field-checkbox-10-5-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-10-5-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Electronic cigarette<\/span><\/label><label id=\"forminator-field-checkbox-10-6-6af65974396eb-label\" for=\"forminator-field-checkbox-10-6-6af65974396eb\" class=\"forminator-checkbox\" title=\"Cigar\"><input type=\"checkbox\" name=\"checkbox-10[]\" value=\"Cigar\" id=\"forminator-field-checkbox-10-6-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-10-6-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cigar<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-11\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-11-6af65974396eb-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-11-6af65974396eb-label\" class=\"forminator-label\">I am easily available for an appointment at the following time(s):<\/span><label id=\"forminator-field-checkbox-11-1-6af65974396eb-label\" for=\"forminator-field-checkbox-11-1-6af65974396eb\" class=\"forminator-checkbox\" title=\"Monday morning\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Monday-morning\" id=\"forminator-field-checkbox-11-1-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-1-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Monday morning<\/span><\/label><label id=\"forminator-field-checkbox-11-2-6af65974396eb-label\" for=\"forminator-field-checkbox-11-2-6af65974396eb\" class=\"forminator-checkbox\" title=\"Monday afternoon\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Monday-afternoon\" id=\"forminator-field-checkbox-11-2-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-2-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Monday afternoon<\/span><\/label><label id=\"forminator-field-checkbox-11-3-6af65974396eb-label\" for=\"forminator-field-checkbox-11-3-6af65974396eb\" class=\"forminator-checkbox\" title=\"Tuesday morning\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Tuesday-morning\" id=\"forminator-field-checkbox-11-3-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-3-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Tuesday morning<\/span><\/label><label id=\"forminator-field-checkbox-11-4-6af65974396eb-label\" for=\"forminator-field-checkbox-11-4-6af65974396eb\" class=\"forminator-checkbox\" title=\"Tuesday afternoon\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Tuesday-afternoon\" 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for=\"forminator-field-checkbox-11-6-6af65974396eb\" class=\"forminator-checkbox\" title=\"Wednesday afternoon\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Wednesday-afternoon\" id=\"forminator-field-checkbox-11-6-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-6-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Wednesday afternoon<\/span><\/label><label id=\"forminator-field-checkbox-11-7-6af65974396eb-label\" for=\"forminator-field-checkbox-11-7-6af65974396eb\" class=\"forminator-checkbox\" title=\"Thursday morning\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Thursday-morning\" id=\"forminator-field-checkbox-11-7-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-7-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thursday morning<\/span><\/label><label id=\"forminator-field-checkbox-11-8-6af65974396eb-label\" for=\"forminator-field-checkbox-11-8-6af65974396eb\" class=\"forminator-checkbox\" title=\"Thursday afternoon\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Thursday-afternoon\" id=\"forminator-field-checkbox-11-8-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-8-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thursday afternoon<\/span><\/label><label id=\"forminator-field-checkbox-11-9-6af65974396eb-label\" for=\"forminator-field-checkbox-11-9-6af65974396eb\" class=\"forminator-checkbox\" title=\"Friday morning\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Friday-morning\" id=\"forminator-field-checkbox-11-9-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-9-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Friday morning<\/span><\/label><label id=\"forminator-field-checkbox-11-10-6af65974396eb-label\" for=\"forminator-field-checkbox-11-10-6af65974396eb\" class=\"forminator-checkbox\" title=\"Friday afternoon\"><input type=\"checkbox\" name=\"checkbox-11[]\" value=\"Friday-afternoon\" id=\"forminator-field-checkbox-11-10-6af65974396eb\" aria-labelledby=\"forminator-field-checkbox-11-10-6af65974396eb-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Friday afternoon<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\" style=\"margin: 0;\"><div id=\"captcha-1\" class=\"forminator-field-captcha  forminator-col-12 \"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"bottomright\" data-sitekey=\"6LchVPIpAAAAABAqVB6Yz6Gfm7EPAPoqTH82eiUD\" data-size=\"invisible\"><\/div> <\/div><\/div><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"consent-2\" class=\"forminator-field-consent forminator-col forminator-col-12  hide-label\"><div class=\"forminator-field\"><label for=\"forminator-field-consent-2_6af65974396eb\" id=\"forminator-field-consent-2_6af65974396eb-label\" class=\"forminator-label\">I agree to the terms and conditions <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-2_6af65974396eb__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-2\" id=\"forminator-field-consent-2_6af65974396eb\" value=\"checked\" aria-labelledby=\"forminator-field-consent-2_6af65974396eb-label\" aria-describedby=\"forminator-field-consent-2_6af65974396eb__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-2_6af65974396eb__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p><span style=\"color: #333333\">I agree to the <a rel=\"noopener\" target=\"_blank\" href=\"https:\/\/dentique.be\/algemene-voowaarden\/\"><u>terms and conditions<\/u><\/a><br><\/span><\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-3\" class=\"forminator-field-consent forminator-col forminator-col-12  hide-label\"><div class=\"forminator-field\"><label for=\"forminator-field-consent-3_6af65974396eb\" id=\"forminator-field-consent-3_6af65974396eb-label\" class=\"forminator-label\">I hereby give permission to send reports, clinical images, and radiological images to a referring dentist or the dental laboratory. <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-3_6af65974396eb__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-3\" id=\"forminator-field-consent-3_6af65974396eb\" value=\"checked\" aria-labelledby=\"forminator-field-consent-3_6af65974396eb-label\" aria-describedby=\"forminator-field-consent-3_6af65974396eb__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-3_6af65974396eb__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p><span style=\"color: #333333\"><span class=\"M7eMe\">I hereby give permission to send reports, clinical images, and radiological images to a referring dentist or the dental laboratory.<br><\/span><\/span><\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12  hide-label\"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_6af65974396eb\" id=\"forminator-field-consent-1_6af65974396eb-label\" class=\"forminator-label\">I agree to the processing and storage of the above data in accordance with GDPR legislation. <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_6af65974396eb__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6af65974396eb\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6af65974396eb-label\" aria-describedby=\"forminator-field-consent-1_6af65974396eb__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6af65974396eb__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p><span style=\"color: #333333\">I agree to the processing and storage of the above data in accordance with GDPR legislation.<br><\/span><\/p><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Verzenden<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"cecfc2e8d1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/1609\" \/><input type=\"hidden\" name=\"form_id\" value=\"1606\"><input type=\"hidden\" name=\"page_id\" value=\"1609\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/dentique.be\/en\/new-patients\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Would you like to register as a new patient? If so, please fill out our application form . Due to high demand, we are currently working with a waiting list. After your application is registered, you will receive a confirmation email. Depending on availability in our schedules, we will then contact you. We look forward&#8230; <\/p>\n<div class=\"buttonwrapper_wrapper\">\n<div class=\"buttonwrapper\"><a class=\"smallbutton\" href=\"https:\/\/dentique.be\/en\/new-patients\/\">Read more<\/a><\/div>\n<\/div>\n","protected":false},"author":2,"featured_media":1081,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-split-screen-medium.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1609","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>New patients &#8212; DENTIQUE<\/title>\n<meta name=\"description\" content=\"Would you like to register as a new patient? If so, please fill out our application form . 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