{"id":1324,"date":"2022-02-17T16:48:51","date_gmt":"2022-02-17T16:48:51","guid":{"rendered":"https:\/\/nzf-freiburg.de\/?page_id=1324"},"modified":"2022-03-02T12:31:03","modified_gmt":"2022-03-02T12:31:03","slug":"anmelung-zu-feriendialyse","status":"publish","type":"page","link":"https:\/\/nzf-freiburg.de\/leistungen\/feriendialyse\/anmelung-zu-feriendialyse\/","title":{"rendered":"Anmelung zu Feriendialyse"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-1360\"><form id=\"wpforms-form-1360\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1360\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/wp-json\/wp\/v2\/pages\/1324?wpforms_form_id=1360\" data-token=\"53deb91de06c39ea11f0fda235890738\"><noscript class=\"wpforms-error-noscript\">Bitte aktiviere JavaScript in deinem Browser, um dieses Formular fertigzustellen.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 3<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:33.333333333333%;background-color:#72b239\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-1360-field_19-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"19\"><\/div><div id=\"wpforms-1360-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_0\">Name \/ Vorname <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1360-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-1360-field_0\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Vorname<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1360-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-1360-field_0-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Nachname<\/label><\/div><\/div><\/div><div id=\"wpforms-1360-field_32-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_32\">Geburtsdatum<\/label><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][32][date][d]\" id=\"wpforms-1360-field_32-day\" class=\"wpforms-field-date-time-date-day\" ><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][32][date][m]\" id=\"wpforms-1360-field_32-month\" class=\"wpforms-field-date-time-date-month\" ><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][32][date][y]\" id=\"wpforms-1360-field_32-year\" class=\"wpforms-field-date-time-date-year\" ><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/div><div id=\"wpforms-1360-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_5\">Stra\u00dfe <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1360-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" required><\/div><div id=\"wpforms-1360-field_6-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_6\">PLZ <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-1360-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-1360-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_7\">Ort <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1360-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/div><div id=\"wpforms-1360-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_8\">Krankenkasse <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-1360-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-1360-field_10-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_10\">R\u00fcckruf erw\u00fcnscht:<\/label><ul id=\"wpforms-1360-field_10\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_10_1\" name=\"wpforms[fields][10]\" value=\"Ja\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_10_1\">Ja<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_10_2\" name=\"wpforms[fields][10]\" value=\"Nein\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_10_2\">Nein<\/label><\/li><\/ul><\/div><div id=\"wpforms-1360-field_9-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"9\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_9\">Telefonnummer mit Vorwahl <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-1360-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" required><\/div><div id=\"wpforms-1360-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1360-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-1360-field_18-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"18\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"1360\" disabled>Weiter<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-1360-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_2\">Adresse &amp; Telefonnummer Heimatdialyse<\/label><textarea id=\"wpforms-1360-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/textarea><\/div><div id=\"wpforms-1360-field_11-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_11\">Patient im NZF bekannt <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1360-field_11\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_11_1\" name=\"wpforms[fields][11]\" value=\"Ja\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_11_1\">Ja<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_11_2\" name=\"wpforms[fields][11]\" value=\"Nein\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_11_2\">Nein<\/label><\/li><\/ul><\/div><div id=\"wpforms-1360-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_12\">Erste Feriendialyse am:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1360-field_12\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][12][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1360-field_13-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_13\">Letzte Dialyse am:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1360-field_13\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][13][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1360-field_14-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_14\">Standortwunsch <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1360-field_14\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_14_1\" name=\"wpforms[fields][14]\" value=\"Freiburg\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_14_1\">Freiburg<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_14_2\" name=\"wpforms[fields][14]\" value=\"Breisach\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_14_2\">Breisach<\/label><\/li><\/ul><\/div><div id=\"wpforms-1360-field_15-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_15\">Dialysetag (nach Wunsch, Mehrfachnennung m\u00f6glich) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1360-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1360-field_15_1\" name=\"wpforms[fields][15][]\" value=\"Mo \/ Mi \/ Fr fr\u00fch\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_15_1\">Mo \/ Mi \/ Fr fr\u00fch<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1360-field_15_2\" name=\"wpforms[fields][15][]\" value=\"Mo \/ Mi \/ Fr sp\u00e4t\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_15_2\">Mo \/ Mi \/ Fr sp\u00e4t<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1360-field_15_3\" name=\"wpforms[fields][15][]\" value=\"Mo \/ Mi \/ Fr abend **\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_15_3\">Mo \/ Mi \/ Fr abend **<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1360-field_15_4\" name=\"wpforms[fields][15][]\" value=\"Mo \/ Mi \/ Fr nachts **\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_15_4\">Mo \/ Mi \/ Fr nachts **<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1360-field_15_5\" name=\"wpforms[fields][15][]\" value=\"Di \/ Do \/ Sa fr\u00fch\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_15_5\">Di \/ Do \/ Sa fr\u00fch<\/label><\/li><\/ul><div class=\"wpforms-field-description\">** Limited Care Dialyse nur am Standort Konrad-Goldmann-Stra\u00dfe \/ Freiburg\r\n(Abenddialyse 18.00 \u2013 22.30 Uhr, Nachtdialyse 21.00 \u2013 5.00 Uhr)<\/div><\/div><div id=\"wpforms-1360-field_16-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_16\">Bett oder Liege<\/label><ul id=\"wpforms-1360-field_16\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_16_1\" name=\"wpforms[fields][16]\" value=\"Bett\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_16_1\">Bett<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_16_2\" name=\"wpforms[fields][16]\" value=\"Liege\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_16_2\">Liege<\/label><\/li><\/ul><\/div><div id=\"wpforms-1360-field_21-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"21\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"1360\" disabled>Weiter<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 last \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-1360-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"22\"><h3 id=\"wpforms-1360-field_22\" name=\"wpforms[fields][22]\">Medizinische Angaben<\/h3><\/div><div id=\"wpforms-1360-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_24\">Medizinische Besonderheiten<\/label><textarea id=\"wpforms-1360-field_24\" class=\"wpforms-field-medium\" name=\"wpforms[fields][24]\" ><\/textarea><\/div><div id=\"wpforms-1360-field_30-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_30\">Dialyse Dokumente<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"30\"\n\t\tdata-form-id=\"1360\"\n\t\tdata-input-name=\"wpforms_1360_30\"\n\t\tdata-extensions=\"pdf\"\n\t\tdata-max-size=\"10485760\"\n\t\tdata-max-file-number=\"3\"\n\t\tdata-post-max-size=\"33554432\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag files to this area to upload.<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 3 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-1360-field_30\"\n\t\tname=\"wpforms_1360_30\" \t\tvalue=\"\">\n<div class=\"wpforms-field-description\">Hier k\u00f6nnen Sie Ihre Unterlagen hochladen (pdf maximal 10 Mb \/ Datei)<\/div><\/div><div id=\"wpforms-1360-field_23-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_23\">Hepatitis B positiv <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1360-field_23\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_23_1\" name=\"wpforms[fields][23]\" value=\"Ja\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_23_1\">Ja<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1360-field_23_2\" name=\"wpforms[fields][23]\" value=\"Nein\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1360-field_23_2\">Nein<\/label><\/li><\/ul><\/div><div id=\"wpforms-1360-field_25-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-1360-field_25\">Hepatitis C positiv <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-1360-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 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