{"id":12741,"date":"2026-08-13T09:55:15","date_gmt":"2026-08-13T07:55:15","guid":{"rendered":"https:\/\/support.mrdm.com\/?post_type=integrations&#038;p=12741"},"modified":"2026-08-13T11:57:42","modified_gmt":"2026-08-13T09:57:42","slug":"aanmeldformulier","status":"publish","type":"integrations","link":"https:\/\/support.mrdm.com\/nl\/koppelingen\/palga\/aanmeldformulier\/","title":{"rendered":"Aanmeldformulier"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Hieronder vind je het PALGA aanmeldformulier.<\/p>\n\n\n<style id=\"wpforms-css-vars-12723\">\n\t\t\t\t#wpforms-12723 {\n\t\t\t\t--wpforms-field-border-size: 2px;\n--wpforms-field-border-radius: 4px;\n--wpforms-field-border-color: #d0d5d9;\n--wpforms-field-border-color-spare: #d0d5d9;\n--wpforms-field-text-color: rgba(0, 0, 0, 0.7);\n--wpforms-label-color: rgba(0, 0, 0, 0.85);\n--wpforms-label-sublabel-color: rgba(0, 0, 0, 0.55);\n--wpforms-button-background-color: #0794ad;\n--wpforms-container-padding: 30px;\n--wpforms-container-border-style: solid;\n--wpforms-container-border-radius: 6px;\n--wpforms-container-border-color: #d0d5d9;\n--wpforms-background-color: #ffffff;\n--wpforms-field-size-input-height: 50px;\n--wpforms-field-size-input-spacing: 20px;\n--wpforms-field-size-font-size: 18px;\n--wpforms-field-size-line-height: 21px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 18px;\n--wpforms-field-size-sublabel-spacing: 10px;\n--wpforms-field-size-icon-size: 1.25;\n--wpforms-label-size-font-size: 18px;\n--wpforms-label-size-line-height: 21px;\n--wpforms-label-size-sublabel-font-size: 16px;\n--wpforms-label-size-sublabel-line-height: 19px;\n--wpforms-button-size-font-size: 20px;\n--wpforms-button-size-height: 48px;\n--wpforms-button-size-padding-h: 20px;\n--wpforms-button-size-margin-top: 15px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-12723-custom-css\">\n\t\t\t\t#wpforms-12723 {\n\t\t\t\t\t.wpforms-form .wpforms-field-divider:first-of-type h3 { margin-top: 0!important; }\r\n.wpforms-form .wpforms-field-divider h3 { padding-top:0; }\r\n.wpforms-form .wpforms-field-divider { border-top-width: 1px; }\n\t\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-12723\"><form id=\"wpforms-form-12723\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"12723\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/nl\/wp-json\/wp\/v2\/integrations\/12741\" data-token=\"0496ec8f76137e691e9d94d517790474\" data-token-time=\"1787369045\"><noscript class=\"wpforms-error-noscript\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Schakel JavaScript in je browser in om dit formulier in te vullen.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-12723-field_2-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"2\"><h3 id=\"wpforms-12723-field_2\" aria-errormessage=\"wpforms-12723-field_2-error\">Instelling<\/h3><\/div><div id=\"wpforms-12723-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_3\">Naam instelling <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-12723-field_3-error\" required><\/div>\t\t<div id=\"wpforms-12723-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-12723-field_1\" >Adres pathologie Aanvullende<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-12723-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-12723-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_4\">Adres instelling <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-12723-field_4-error\" required><\/div><div id=\"wpforms-12723-field_6-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"6\"><h3 id=\"wpforms-12723-field_6\" aria-errormessage=\"wpforms-12723-field_6-error\">Benodigde gegevens<\/h3><\/div><div id=\"wpforms-12723-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_7\">Decentraal pathologie laboratorium <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_7\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][7]\" aria-errormessage=\"wpforms-12723-field_7-error\" required><\/div><div id=\"wpforms-12723-field_8-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-type=\"checkbox\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">Registraties<\/legend><ul id=\"wpforms-12723-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-12723-field_8_1\" name=\"wpforms[fields][8][]\" value=\"DCRA\" aria-errormessage=\"wpforms-12723-field_8_1-error\" aria-describedby=\"wpforms-12723-field_8-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12723-field_8_1\">DCRA<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-12723-field_8_2\" name=\"wpforms[fields][8][]\" value=\"DGEA\" aria-errormessage=\"wpforms-12723-field_8_2-error\" aria-describedby=\"wpforms-12723-field_8-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12723-field_8_2\">DGEA<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-12723-field_8_3\" name=\"wpforms[fields][8][]\" value=\"DUCA\" aria-errormessage=\"wpforms-12723-field_8_3-error\" aria-describedby=\"wpforms-12723-field_8-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12723-field_8_3\">DUCA<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-12723-field_8_4\" name=\"wpforms[fields][8][]\" value=\"DMTR\" aria-errormessage=\"wpforms-12723-field_8_4-error\" aria-describedby=\"wpforms-12723-field_8-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12723-field_8_4\">DMTR<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-12723-field_8_5\" name=\"wpforms[fields][8][]\" value=\"DPCA\" aria-errormessage=\"wpforms-12723-field_8_5-error\" aria-describedby=\"wpforms-12723-field_8-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12723-field_8_5\">DPCA<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-12723-field_8_6\" name=\"wpforms[fields][8][]\" value=\"DPA\" aria-errormessage=\"wpforms-12723-field_8_6-error\" aria-describedby=\"wpforms-12723-field_8-description\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12723-field_8_6\">DPA<\/label><\/li><\/ul><div id=\"wpforms-12723-field_8-description\" class=\"wpforms-field-description\">Selecteer hier voor welke registraties u de PALGA-koppeling wilt activeren<\/div><\/fieldset><\/div><div id=\"wpforms-12723-field_10-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"10\"><h3 id=\"wpforms-12723-field_10\" aria-errormessage=\"wpforms-12723-field_10-error\" aria-describedby=\"wpforms-12723-field_10-description\">Contactpersoon voor Pathologie-Connect contract<\/h3><div id=\"wpforms-12723-field_10-description\" class=\"wpforms-field-description\">Om gebruik te kunnen maken van de PALGA-koppeling, dient er een Pathologie-Connect contract ondertekend te worden. Graag vernemen wij wie binnen uw instelling het contract mag ontvangen. Het betreft hier een contract zonder kosten voor het ziekenhuis.<\/div><\/div><div id=\"wpforms-12723-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_11\">Naam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_11\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-12723-field_11-error\" required><\/div><div id=\"wpforms-12723-field_12-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_12\">E-mailadres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12723-field_12\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][12]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12723-field_12-error\" required><\/div><div id=\"wpforms-12723-field_13-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_13\">Telefoonnummer<\/label><input type=\"tel\" id=\"wpforms-12723-field_13\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][13]\" aria-label=\"Telefoonnummer\" aria-errormessage=\"wpforms-12723-field_13-error\" ><\/div><div id=\"wpforms-12723-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_14\">Functietitel<\/label><input type=\"text\" id=\"wpforms-12723-field_14\" class=\"wpforms-field-large\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-12723-field_14-error\" ><\/div><div id=\"wpforms-12723-field_21-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"21\"><h3 id=\"wpforms-12723-field_21\" aria-errormessage=\"wpforms-12723-field_21-error\" aria-describedby=\"wpforms-12723-field_21-description\">Contactpersoon voor vragen<\/h3><div id=\"wpforms-12723-field_21-description\" class=\"wpforms-field-description\">Het kan voorkomen dat er vragen zijn omtrent de PALGA-koppeling die door de organisatie beantwoord moeten worden. Graag vernemen wij wie de contactpersonen zijn die wij kunnen benaderen. <\/div><\/div><div id=\"wpforms-12723-field_15-container\" class=\"wpforms-field wpforms-field-repeater wpforms-field-repeater-display-blocks\" data-rows-min=\"1\" data-rows-max=\"3\" data-clone-num=\"2\" data-field-type=\"repeater\" data-field-id=\"15\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tContactpersoon\n\t\t\t<\/h3><input type=\"hidden\" class=\"wpforms-field-repeater-clone-list\" name=\"wpforms[fields][15][clone_list]\" value=\"[]\"><script type=\"text\/html\" class=\"tmpl-wpforms-field-repeater-template-15-12723\"><div id=\"wpforms-12723-repeater-field_15-clone_{CLONE}\" class=\"wpforms-field-repeater-clone-wrap\" data-clone=\"{CLONE}\">\n\t\t\t\t<h3 class=\"wpforms-field-repeater-block-title\">\n\t\t\t\tContactpersoon <span class=\"wpforms-wpforms-field-repeater-block-num\">#{CLONE}<\/span>\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large wpforms-field-repeater-display-blocks wpforms-field-repeater-preset-100\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_17_{CLONE}-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"17_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_17_{CLONE}\">Naam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_17_{CLONE}\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][17_{CLONE}]\" aria-errormessage=\"wpforms-12723-field_17_{CLONE}-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_18_{CLONE}-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"18_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_18_{CLONE}\">E-mailadres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12723-field_18_{CLONE}\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][18_{CLONE}]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12723-field_18_{CLONE}-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_19_{CLONE}-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"19_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_19_{CLONE}\">Telefoonnummer<\/label><input type=\"tel\" id=\"wpforms-12723-field_19_{CLONE}\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][19_{CLONE}]\" aria-label=\"Telefoonnummer\" aria-errormessage=\"wpforms-12723-field_19_{CLONE}-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_20_{CLONE}-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"20_{CLONE}\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_20_{CLONE}\">Functietitel<\/label><input type=\"text\" id=\"wpforms-12723-field_20_{CLONE}\" class=\"wpforms-field-large\" name=\"wpforms[fields][20_{CLONE}]\" aria-errormessage=\"wpforms-12723-field_20_{CLONE}-error\" ><\/div><\/div><\/div><\/div><div class=\"wpforms-field-repeater-display-blocks-buttons\" data-button-type=\"buttons_with_icons\">\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-add\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.129 7.984v1.032a.392.392 0 0 1-.387.387H8.903v2.839a.392.392 0 0 1-.387.387H7.484a.373.373 0 0 1-.387-.387V9.403H4.258a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h2.839V4.758c0-.193.161-.387.387-.387h1.032c.194 0 .387.194.387.387v2.839h2.839c.193 0 .387.193.387.387ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Contactpersoon toevoegen<\/span>\n\t\t\t\t<\/button>\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-remove wpforms-disabled\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M4.258 9.403a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h7.484c.193 0 .387.193.387.387v1.032a.392.392 0 0 1-.387.387H4.258ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Verwijderen<\/span>\n\t\t\t\t<\/button>\n\t\t\t<\/div>\n\t\t\t<\/div><\/script><div class=\"wpforms-field-layout-rows wpforms-field-large wpforms-field-repeater-display-blocks wpforms-field-repeater-preset-100\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_17\">Naam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_17\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-12723-field_17-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_18-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_18\">E-mailadres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12723-field_18\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][18]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12723-field_18-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_19-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_19\">Telefoonnummer<\/label><input type=\"tel\" id=\"wpforms-12723-field_19\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][19]\" aria-label=\"Telefoonnummer\" aria-errormessage=\"wpforms-12723-field_19-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-12723-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_20\">Functietitel<\/label><input type=\"text\" id=\"wpforms-12723-field_20\" class=\"wpforms-field-large\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-12723-field_20-error\" ><\/div><\/div><\/div><\/div><div class=\"wpforms-field-repeater-display-blocks-buttons\" data-button-type=\"buttons_with_icons\">\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-add\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M12.129 7.984v1.032a.392.392 0 0 1-.387.387H8.903v2.839a.392.392 0 0 1-.387.387H7.484a.373.373 0 0 1-.387-.387V9.403H4.258a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h2.839V4.758c0-.193.161-.387.387-.387h1.032c.194 0 .387.194.387.387v2.839h2.839c.193 0 .387.193.387.387ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Contactpersoon toevoegen<\/span>\n\t\t\t\t<\/button>\n\t\t\t\t<button type=\"button\" class=\"wpforms-field-repeater-button-remove wpforms-disabled\">\n\t\t\t\t\t<svg width=\"16\" height=\"17\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M4.258 9.403a.373.373 0 0 1-.387-.387V7.984c0-.194.161-.387.387-.387h7.484c.193 0 .387.193.387.387v1.032a.392.392 0 0 1-.387.387H4.258ZM16 8.5c0 4.42-3.58 8-8 8s-8-3.58-8-8 3.58-8 8-8 8 3.58 8 8Zm-1.548 0c0-3.548-2.904-6.452-6.452-6.452A6.45 6.45 0 0 0 1.548 8.5 6.43 6.43 0 0 0 8 14.952 6.45 6.45 0 0 0 14.452 8.5Z\" fill=\"currentColor\"\/><\/svg><span>Verwijderen<\/span>\n\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"wpforms-12723-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"22\"><h3 id=\"wpforms-12723-field_22\" aria-errormessage=\"wpforms-12723-field_22-error\" aria-describedby=\"wpforms-12723-field_22-description\">Toestemming PALGA-koppeling<\/h3><div id=\"wpforms-12723-field_22-description\" class=\"wpforms-field-description\">Hierbij gaat de zorginstelling, bij naam van ondergetekende, akkoord met het verwerken door MRDM van PALGA pathologiegegevens voor de op dit formulier aangegeven registraties.<\/div><\/div><div id=\"wpforms-12723-field_27-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Akkoordverklaring <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-12723-field_27\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-12723-field_27_1\" name=\"wpforms[fields][27][]\" value=\"Hierbij verklaar ik bevoegd te zijn om namens de zorginstelling akkoord te gaan met het verwerken door MRDM van PALGA-pathologiegegevens voor de op dit formulier aangegeven registraties.\" aria-errormessage=\"wpforms-12723-field_27_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12723-field_27_1\">Hierbij verklaar ik bevoegd te zijn om namens de zorginstelling akkoord te gaan met het verwerken door MRDM van PALGA-pathologiegegevens voor de op dit formulier aangegeven registraties.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12723-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-field-readonly\" data-field-type=\"text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_29\">Datum<\/label><input type=\"text\" id=\"wpforms-12723-field_29\" class=\"wpforms-field-large\" name=\"wpforms[fields][29]\" value=\"22\u00a0augustus 2026\" aria-errormessage=\"wpforms-12723-field_29-error\" ><\/div><div id=\"wpforms-12723-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_26\">Naam ondertekende <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-12723-field_26-error\" required><\/div><div id=\"wpforms-12723-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-12723-field_25\">Naam instelling <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12723-field_25\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-12723-field_25-error\" required><\/div><div id=\"wpforms-12723-field_28-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"28\"><h3 id=\"wpforms-12723-field_28\" aria-errormessage=\"wpforms-12723-field_28-error\" aria-describedby=\"wpforms-12723-field_28-description\">Aanvullende instructie deelname PALGA-koppeling<\/h3><div id=\"wpforms-12723-field_28-description\" class=\"wpforms-field-description\">Om de gegevens vanuit PALGA met behulp van de PALGA-koppeling in de registraties te verwerken, dient het betreffende pathologie laboratorium een verzoek in te dienen bij ICT Nederland. Dit kan het pathologie laboratorium doen door een ticket aan te maken bij ICT Nederland en daarin aan te geven voor welke registratie(s) de PALGA-koppeling geactiveerd kan worden. 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