{"id":3388,"date":"2022-04-12T07:45:29","date_gmt":"2022-04-12T05:45:29","guid":{"rendered":"https:\/\/support.mrdm.com\/?post_type=sign-up&#038;p=3388"},"modified":"2026-07-21T10:16:39","modified_gmt":"2026-07-21T08:16:39","slug":"aanmeldformulier","status":"publish","type":"sign-up","link":"https:\/\/support.mrdm.com\/nl\/aanmelden\/aanmelden\/aanmeldformulier\/","title":{"rendered":"Aanmeldformulier"},"content":{"rendered":"\n<div class=\"acf-conditional-content\">\n\n<style id=\"wpforms-css-vars-12303\">\n\t\t\t\t#wpforms-12303 {\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-12303-custom-css\">\n\t\t\t\t#wpforms-12303 {\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-12303\"><form id=\"wpforms-form-12303\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"12303\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/nl\/wp-json\/wp\/v2\/sign-up\/3388\" data-token=\"40bad2b1681564f92f213bca2ce39d68\" data-token-time=\"1784668240\"><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-12303-field_25-container\" class=\"wpforms-field wpforms-field-divider wpforms-field-divider-hide_line\" data-field-type=\"divider\" data-field-id=\"25\"><h3 id=\"wpforms-12303-field_25\" aria-errormessage=\"wpforms-12303-field_25-error\">Registratie<\/h3><\/div>\t\t<div id=\"wpforms-12303-field_11-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"11\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-12303-field_11\" >Registratie Naam Nummer<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-12303-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-12303-field_1-container\" class=\"wpforms-field wpforms-field-select mrdm-registratie wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_1\">Registratie <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-12303-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Kies registratie<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,codman,integrations,amsm,swab|label=AMSM%20%28Antimicrobial%20stewardship%29\"  class=\"choice-1 depth-1\"  >AMSM (Antimicrobial stewardship)<\/option><option value=\"sign-up,account,downloads,batch,born,vsbn|label=BORN%20%28Brandwonden%29\"  class=\"choice-2 depth-1\"  >BORN (Brandwonden)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,data-verification,medical-questions,daci,dica|label=DACI%20%28halsslagader%20interventies%29\"  class=\"choice-3 depth-1\"  >DACI (halsslagader interventies)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,codman,medical-questions,dasa,dica|label=DASA%20%28beroertezorg%29\"  class=\"choice-4 depth-1\"  >DASA (beroertezorg)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,proms,data-verification,medical-questions,dato,dica|label=DATO%20%28obesitas%29\"  class=\"choice-5 depth-1\"  >DATO (obesitas)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,codman,data-verification,dbir,dica|label=DBIR%20%28borstimplantaten%29\"  class=\"choice-6 depth-1\"  >DBIR (borstimplantaten)<\/option><option value=\"sign-up,account,downloads,batch,data-verification,dbir-suppliers,dica|label=DBIR-Suppliers\"  class=\"choice-7 depth-1\"  >DBIR-Suppliers<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,proms,data-verification,medical-questions,dcra,dica|label=DCRA%20%28darmkanker%29\"  class=\"choice-8 depth-1\"  >DCRA (darmkanker)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,integrations,data-verification,medical-questions,dcra-r,dica|label=DCRA-R\"  class=\"choice-9 depth-1\"  >DCRA-R<\/option><option value=\"sign-up,account,downloads,codman,self-service-portal,integrations,dgda,dica|label=DGDA%20%28galsteenlijden%29\"  class=\"choice-10 depth-1\"  >DGDA (galsteenlijden)<\/option><option value=\"sign-up,account,downloads,batch,codman,integrations,data-verification,medical-questions,dgea,dica|label=DGEA%20%28kijkonderzoek%20maag%2Fdarm%2Flever%29\"  class=\"choice-11 depth-1\"  >DGEA (kijkonderzoek maag\/darm\/lever)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,codman,proms,data-verification,medical-questions,integrations,dgoa,dica|label=DGOA%20%28gynaecologische%20oncologie%29\"  class=\"choice-12 depth-1\"  >DGOA (gynaecologische oncologie)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,data-verification,medical-questions,dgoa-r,dica|label=DGOA-R\"  class=\"choice-13 depth-1\"  >DGOA-R<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,data-verification,dhba,dica|label=DHBA%20%28lever-%20en%20galwegen%29\"  class=\"choice-14 depth-1\"  >DHBA (lever- en galwegen)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,proms,data-verification,medical-questions,dhfa,dica|label=DHFA%20%28heupfractuur%29\"  class=\"choice-15 depth-1\"  >DHFA (heupfractuur)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,codman,proms,data-verification,medical-questions,integrations,dhna,dica|label=DHNA%20%28hoofd-hals%20oncologie%29\"  class=\"choice-16 depth-1\"  >DHNA (hoofd-hals oncologie)<\/option><option value=\"sign-up,account,downloads,integrations,diha,dica|label=DIHA%20%28liesbreuk%29\"  class=\"choice-17 depth-1\"  >DIHA (liesbreuk)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,codman,data-verification,medical-questions,integrations,dlca-l,dica|label=DLCA-L\"  class=\"choice-18 depth-1\"  >DLCA-L<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,data-verification,medical-questions,dlca-r,dica|label=DLCA-R\"  class=\"choice-19 depth-1\"  >DLCA-R<\/option><option value=\"sign-up,account,downloads,dataentry,batch,transparency,codman,data-verification,self-service-portal,integrations,dlca-s,dica|label=DLCA-S\"  class=\"choice-20 depth-1\"  >DLCA-S<\/option><option value=\"sign-up,account,codman,batch,integrations,medical-questions,dma,dica|label=DMA%20%28geneesmiddelen%29\"  class=\"choice-21 depth-1\"  >DMA (geneesmiddelen)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,codman,proms,data-verification,medical-questions,integrations,dmtr,dica|label=DMTR%20%28melanoom%29\"  class=\"choice-22 depth-1\"  >DMTR (melanoom)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,codman,proms,data-verification,medical-questions,integrations,dnma,dica|label=DNMA%20%28neuromodulatie%29\"  class=\"choice-23 depth-1\"  >DNMA (neuromodulatie)<\/option><option value=\"sign-up,account,downloads,dataentry,batch,integrations,dpa,dica|label=DPA%20%28prostaatkanker%29\"  class=\"choice-24 depth-1\"  >DPA (prostaatkanker)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,data-verification,integrations,dpaa,dica|label=DPAA%20%28perioperatieve%20anesthesiologie%29\"  class=\"choice-25 depth-1\"  >DPAA (perioperatieve anesthesiologie)<\/option><option value=\"sign-up,account,self-service-portal,downloads,batch,transparency,codman,integrations,data-verification,medical-questions,dpard,dica|label=DPARD%20%28diabetes%29\"  class=\"choice-26 depth-1\"  >DPARD (diabetes)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,codman,data-verification,medical-questions,integrations,dpca,dica|label=DPCA%20%28alvleesklierkanker%29\"  class=\"choice-27 depth-1\"  >DPCA (alvleesklierkanker)<\/option><option value=\"sign-up,account,self-service-portal,downloads,batch,codman,proms,data-verification,integrations,dppa,dica|label=DPPA%20%28pijn%20en%20palliatieve%20zorg%29\"  class=\"choice-28 depth-1\"  >DPPA (pijn en palliatieve zorg)<\/option><option value=\"sign-up,account,self-service-portal,downloads,batch,codman,draim,niv|label=DRAIM%20%28Acute%20interne%20geneeskunde%29\"  class=\"choice-29 depth-1\"  >DRAIM (Acute interne geneeskunde)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,codman,data-verification,drce,dica|label=DRCE%20%28complicaties%20kijkonderzoek%29\"  class=\"choice-30 depth-1\"  >DRCE (complicaties kijkonderzoek)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,data-verification,medical-questions,dsaa,dica|label=DSAA%20%28aorta%20interventies%29\"  class=\"choice-31 depth-1\"  >DSAA (aorta interventies)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,proms,data-verification,medical-questions,duca,dica|label=DUCA%20%28maag-%20en%20slokdarmkanker%29\"  class=\"choice-32 depth-1\"  >DUCA (maag- en slokdarmkanker)<\/option><option value=\"sign-up,self-service-portal,downloads,dataentry,medical-questions,ehr,sein|label=EHR%20%28European%20Hypersomnolence%20Registry%29\"  class=\"choice-33 depth-1\"  >EHR (European Hypersomnolence Registry)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,codman,data-verification,epsa,dica|label=EPSA%20%28kinderchirurgie%29\"  class=\"choice-34 depth-1\"  >EPSA (kinderchirurgie)<\/option><option value=\"sign-up,account,downloads,dataentry,batch,hemoned|label=HemoNED%20%28Hemofilie%29\"  class=\"choice-35 depth-1\"  >HemoNED (Hemofilie)<\/option><option value=\"sign-up,account,self-service-portal,downloads,dataentry,batch,transparency,integrations,codman,proms,data-verification,medical-questions,nbca,dica|label=NBCA%20%28borstkanker%29\"  class=\"choice-36 depth-1\"  >NBCA (borstkanker)<\/option><option value=\"sign-up,account,self-service-portal,downloads,codman,dataentry,batch,integrations,data-verification,medical-questions,data-exports,nbca-r,dica|label=NBCA-R\"  class=\"choice-37 depth-1\"  >NBCA-R<\/option><option value=\"sign-up,account,self-service-portal,downloads,batch,dataentry,nbr-r3,vsbn|label=NBR-R3%20%28Brandwonden%29\"  class=\"choice-38 depth-1\"  >NBR-R3 (Brandwonden)<\/option><option value=\"sign-up,account,self-service-portal,batch,downloads,dataentry,codman,pice|label=PICE%20%28Pediatrische%20Intensive%20Care%29\"  class=\"choice-39 depth-1\"  >PICE (Pediatrische Intensive Care)<\/option><\/select><div id=\"wpforms-12303-field_1-description\" class=\"wpforms-field-description\">Voor welke registratie wilt u zich aanmelden?<\/div><\/div><div id=\"wpforms-12303-field_35-container\" class=\"wpforms-field wpforms-field-hidden sync-mrdm-registratie wpforms-conditional-trigger\" data-field-type=\"hidden\" data-field-id=\"35\"><input type=\"hidden\" id=\"wpforms-12303-field_35\" name=\"wpforms[fields][35]\" value=\"This field will be automatically populated with the value of the registratie input\"><\/div><div id=\"wpforms-12303-field_40-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"40\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Type uitkomsten<\/legend><ul id=\"wpforms-12303-field_40\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-12303-field_40_1\" name=\"wpforms[fields][40]\" value=\"Klinisch\" aria-errormessage=\"wpforms-12303-field_40_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_40_1\">Klinisch<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-12303-field_40_2\" name=\"wpforms[fields][40]\" value=\"PROMs\" aria-errormessage=\"wpforms-12303-field_40_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_40_2\">PROMs<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-12303-field_40_3\" name=\"wpforms[fields][40]\" value=\"Klinisch &amp; PROMs\" aria-errormessage=\"wpforms-12303-field_40_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_40_3\">Klinisch &amp; PROMs<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12303-field_2-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"2\"><h3 id=\"wpforms-12303-field_2\" aria-errormessage=\"wpforms-12303-field_2-error\">Uw gegevens<\/h3><\/div><div id=\"wpforms-12303-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_3\">Uw naam <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12303-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" aria-errormessage=\"wpforms-12303-field_3-error\" required><\/div><div id=\"wpforms-12303-field_4-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_4\">Uw e-mailadres <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12303-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12303-field_4-error\" required><\/div><div id=\"wpforms-12303-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_5\">Functietitel <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12303-field_5\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-12303-field_5-error\" required><\/div><div id=\"wpforms-12303-field_6-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"6\"><h3 id=\"wpforms-12303-field_6\" aria-errormessage=\"wpforms-12303-field_6-error\" aria-describedby=\"wpforms-12303-field_6-description\">Contactpersoon<\/h3><div id=\"wpforms-12303-field_6-description\" class=\"wpforms-field-description\">Voor elke registratie heeft een organisatie een contactpersoon nodig. De contactpersoon kan accounts aanvragen voor andere gebruikers. Als u niet de contactpersoon bent, moet u iemand anders opgeven die deze rol gaat vervullen.\n\n<\/div><\/div><div id=\"wpforms-12303-field_7-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-type=\"radio\" data-field-id=\"7\"><fieldset><legend class=\"wpforms-field-label\">Contactpersoon <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-12303-field_7\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-12303-field_7_1\" name=\"wpforms[fields][7]\" value=\"Ik ben contactpersoon\" aria-errormessage=\"wpforms-12303-field_7_1-error\" required  checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_7_1\">Ik ben contactpersoon<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-12303-field_7_2\" name=\"wpforms[fields][7]\" value=\"Ik ben geen contactpersoon\" aria-errormessage=\"wpforms-12303-field_7_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_7_2\">Ik ben geen contactpersoon<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12303-field_8-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"text\" data-field-id=\"8\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_8\">Naam contactpersson <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12303-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" aria-errormessage=\"wpforms-12303-field_8-error\" required><\/div><div id=\"wpforms-12303-field_9-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"email\" data-field-id=\"9\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_9\">E-mailadres contactpersoon <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12303-field_9\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][9]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12303-field_9-error\" required><\/div><div id=\"wpforms-12303-field_43-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"43\"><h3 id=\"wpforms-12303-field_43\" aria-errormessage=\"wpforms-12303-field_43-error\" aria-describedby=\"wpforms-12303-field_43-description\">Tekenbevoegde<\/h3><div id=\"wpforms-12303-field_43-description\" class=\"wpforms-field-description\">De tekenbevoegde is de persoon die namens de organisatie rechtsgeldig de contracten mag ondertekenen.<\/div><\/div><div id=\"wpforms-12303-field_46-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_46\">E-mailadres tekenbevoegde <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-12303-field_46\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][46]\" spellcheck=\"false\" aria-errormessage=\"wpforms-12303-field_46-error\" required><\/div><div id=\"wpforms-12303-field_10-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"10\"><h3 id=\"wpforms-12303-field_10\" aria-errormessage=\"wpforms-12303-field_10-error\">Organisatie<\/h3><\/div><div id=\"wpforms-12303-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_14\">Uw instelling <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-12303-field_14\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-12303-field_14-error\" aria-describedby=\"wpforms-12303-field_14-description\" required><div id=\"wpforms-12303-field_14-description\" class=\"wpforms-field-description\">Indien er meerdere locaties zijn, graag erbij vermelden voor welke locatie\n<\/div><\/div><div id=\"wpforms-12303-field_15-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"15\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12303-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_16\">Straatnaam<\/label><input type=\"text\" id=\"wpforms-12303-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-12303-field_16-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12303-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_17\">Nummer<\/label><input type=\"text\" id=\"wpforms-12303-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-12303-field_17-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12303-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_19\">Postcode<\/label><input type=\"text\" id=\"wpforms-12303-field_19\" class=\"wpforms-field-medium wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"9999AA\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-12303-field_19-error\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-12303-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_20\">Plaats<\/label><input type=\"text\" id=\"wpforms-12303-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" aria-errormessage=\"wpforms-12303-field_20-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-12303-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_21\">AGB-code<\/label><input type=\"text\" id=\"wpforms-12303-field_21\" class=\"wpforms-field-large wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99999999\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-12303-field_21-error\" ><\/div><div id=\"wpforms-12303-field_42-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-12303-field_42\">KVK-nummer<\/label><input type=\"text\" id=\"wpforms-12303-field_42\" class=\"wpforms-field-large wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99999999\" name=\"wpforms[fields][42]\" aria-errormessage=\"wpforms-12303-field_42-error\" ><\/div><div id=\"wpforms-12303-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"22\"><h3 id=\"wpforms-12303-field_22\" aria-errormessage=\"wpforms-12303-field_22-error\" aria-describedby=\"wpforms-12303-field_22-description\">Data-aanlevering<\/h3><div id=\"wpforms-12303-field_22-description\" class=\"wpforms-field-description\">Hoe wilt u data gaan aanleveren voor deze registratie?<\/div><\/div><div id=\"wpforms-12303-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"24\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Klinisch<\/legend><ul id=\"wpforms-12303-field_24\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-12303-field_24_1\" name=\"wpforms[fields][24][]\" value=\"Handmatige aanlevering (DataEntry)\" aria-errormessage=\"wpforms-12303-field_24_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_24_1\">Handmatige aanlevering (DataEntry)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-12303-field_24_2\" name=\"wpforms[fields][24][]\" value=\"Batch-aanlevering (DataConnect)\" aria-errormessage=\"wpforms-12303-field_24_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_24_2\">Batch-aanlevering (DataConnect)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12303-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"38\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Proms<\/legend><ul id=\"wpforms-12303-field_38\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-12303-field_38_1\" name=\"wpforms[fields][38][]\" value=\"DICA basissysteem\" aria-errormessage=\"wpforms-12303-field_38_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_38_1\">DICA basissysteem<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-12303-field_38_2\" name=\"wpforms[fields][38][]\" value=\"Batch-aanlevering (DataConnect)\" aria-errormessage=\"wpforms-12303-field_38_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_38_2\">Batch-aanlevering (DataConnect)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12303-field_39-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-type=\"checkbox\" data-field-id=\"39\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Proms DUCA<\/legend><ul id=\"wpforms-12303-field_39\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-12303-field_39_1\" name=\"wpforms[fields][39][]\" value=\"DICA basissysteem\" aria-errormessage=\"wpforms-12303-field_39_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_39_1\">DICA basissysteem<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-12303-field_39_2\" name=\"wpforms[fields][39][]\" value=\"Batch-aanlevering (DataConnect)\" aria-errormessage=\"wpforms-12303-field_39_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_39_2\">Batch-aanlevering (DataConnect)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-12303-field_39_3\" name=\"wpforms[fields][39][]\" value=\"POCOP-aanlevering\" aria-errormessage=\"wpforms-12303-field_39_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-12303-field_39_3\">POCOP-aanlevering<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-12303-field_29-container\" class=\"wpforms-field wpforms-field-html\" data-field-type=\"html\" data-field-id=\"29\"><div id=\"wpforms-12303-field_29\" aria-errormessage=\"wpforms-12303-field_29-error\"><br \/><br \/><\/div><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-12303-field_11-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 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laden\"><\/div><\/form><\/div>  <!-- .wpforms-container 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