{"id":417,"date":"2022-08-03T07:35:52","date_gmt":"2022-08-03T07:35:52","guid":{"rendered":"https:\/\/rueckenmedizin.ch\/zuweiser\/"},"modified":"2022-09-27T07:30:41","modified_gmt":"2022-09-27T07:30:41","slug":"zuweiser","status":"publish","type":"page","link":"https:\/\/rueckenmedizin.ch\/en\/zuweiser\/","title":{"rendered":"Referring doctor"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;rgba(254,243,213,0.71)&#8221; background_image=&#8221;https:\/\/rueckenmedizin.ch\/wp-content\/uploads\/2022\/08\/vorschau-services.jpg&#8221; background_blend=&#8221;screen&#8221; custom_padding=&#8221;80px||62px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text module_class=&#8221;crimson&#8221; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; header_font_size=&#8221;56px&#8221; header_line_height=&#8221;76px&#8221; custom_margin=&#8221;||16px||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1 style=\"text-align: center;\"><strong>Referring doctor<\/strong><\/h1>\n<p>[\/et_pb_text][et_pb_divider color=&#8221;#516770&#8243; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; background_enable_color=&#8221;off&#8221; max_width=&#8221;160px&#8221; module_alignment=&#8221;center&#8221; height=&#8221;1px&#8221; custom_margin=&#8221;0px||24px||false|false&#8221; custom_padding=&#8221;0px||0px||false|false&#8221; border_color_all=&#8221;#516770&#8243; global_colors_info=&#8221;{}&#8221;][\/et_pb_divider][lwp_divi_breadcrumbs home_text=&#8221;Homepage&#8221; font_icon=&#8221;&#x35;||divi||400&#8243; link_color=&#8221;#516770&#8243; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; module_text_align=&#8221;center&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;][\/lwp_divi_breadcrumbs][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#fdf4d5&#8243; custom_padding=&#8221;82px||||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row module_id=&#8221;zuweiser&#8221; module_class=&#8221;centerfeld&#8221; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#FFFFFF&#8221; custom_padding=&#8221;40px|40px|40px|40px|false|false&#8221; animation_style=&#8221;slide&#8221; animation_direction=&#8221;bottom&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text module_class=&#8221;crimson&#8221; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; header_2_font=&#8221;|800|||||||&#8221; header_2_font_size=&#8221;30px&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Referral or request from doctor:<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; text_line_height=&#8221;25px&#8221; custom_padding=&#8221;|||20px|false|false&#8221; custom_padding_tablet=&#8221;|||0px|false|false&#8221; custom_padding_phone=&#8221;|||0px|false|false&#8221; custom_padding_last_edited=&#8221;on|tablet&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><span><script>\nvar 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name='input_6.2' type='checkbox'  value='Thoracic pain'  id='choice_7_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_2' id='label_7_6_2' class='gform-field-label gform-field-label--type-inline'>Thoracic pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='Cervical pain'  id='choice_7_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_3' id='label_7_6_3' class='gform-field-label gform-field-label--type-inline'>Cervical pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='Cervicobrachial pain'  id='choice_7_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_4' id='label_7_6_4' class='gform-field-label gform-field-label--type-inline'>Cervicobrachial pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='Disorder of the cranial nerves, including epilepsy'  id='choice_7_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_5' id='label_7_6_5' class='gform-field-label gform-field-label--type-inline'>Disorder of the cranial nerves, including epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.6' type='checkbox'  value='Lumbo-ischial pain and\/or lumbo-femoral pain'  id='choice_7_6_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_6' id='label_7_6_6' class='gform-field-label gform-field-label--type-inline'>Lumbo-ischial pain and\/or lumbo-femoral pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.7' type='checkbox'  value='Mainly left side'  id='choice_7_6_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_7' id='label_7_6_7' class='gform-field-label gform-field-label--type-inline'>Mainly left side<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.8' type='checkbox'  value='Mainly right side'  id='choice_7_6_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_8' id='label_7_6_8' class='gform-field-label gform-field-label--type-inline'>Mainly right side<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.9' type='checkbox'  value='Paresis, hyposensitivity, paraesthesia'  id='choice_7_6_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_9' id='label_7_6_9' class='gform-field-label gform-field-label--type-inline'>Paresis, hyposensitivity, paraesthesia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.11' type='checkbox'  value='An X-ray (ap\/lat) is available.'  id='choice_7_6_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_11' id='label_7_6_11' class='gform-field-label gform-field-label--type-inline'>An X-ray (ap\/lat) is available.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.12' type='checkbox'  value='An MRI is available.'  id='choice_7_6_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_12' id='label_7_6_12' class='gform-field-label gform-field-label--type-inline'>An MRI is available.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.13' type='checkbox'  value='There are currently no radiological examinations less than 3 months old. 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gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Datenschutz<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_5'><div class='gchoice gchoice_7_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='I accept the &lt;a href=&quot;https:\/\/rueckenmedizin.ch\/en\/privacy-policy\/&quot; target=&quot;_blank&quot;&gt;Privacy Policy&lt;\/a&gt;'  id='choice_7_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_5_1' id='label_7_5_1' class='gform-field-label gform-field-label--type-inline'>I accept the <a href=\"https:\/\/rueckenmedizin.ch\/en\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_7' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Please schedule an appointment with the patient.'  \/> <input type='hidden' name='gform_ajax' value='form_id=7&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=e1938d96c36a6f420f2cc5932eb83cb1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_7' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_7' id='gform_theme_7' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_7' id='gform_style_settings_7' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_7' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='7' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='xkKavqwoOmQDZQ5g05LGEx2xjVZgIiQPj376qHZYYdIGZPrAXaLnf6Bth+dzMwwgRWeXG9+e0HgWrAX44tG2xXZ5hyNejbEFKU2hN56\/\/d9oV+w=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_7' value='WyJbXSIsImNhYzAyNWVjM2UzYzUyODVkY2YzNDcxMzIxYzFlOThlIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_7' id='gform_target_page_number_7' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_7' id='gform_source_page_number_7' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_7' id='gform_ajax_frame_7' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 7, 'https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_7').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_7');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_7').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_7').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_7').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_7').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_7').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_7').val();gformInitSpinner( 7, 'https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [7, current_page]);window['gf_submitting_7'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_7').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_7').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [7]);window['gf_submitting_7'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_7').text());}else{jQuery('#gform_7').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"7\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_7\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_7\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_7\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 7, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n<\/span><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; disabled_on=&#8221;on|on|on&#8221; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#fdf4d5&#8243; custom_padding=&#8221;82px||||false|false&#8221; disabled=&#8221;on&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row module_id=&#8221;zuweiser&#8221; module_class=&#8221;centerfeld&#8221; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#FFFFFF&#8221; custom_padding=&#8221;40px|40px|40px|40px|false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; header_2_font=&#8221;|800|||||||&#8221; header_2_font_size=&#8221;30px&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>Zuweiser<\/h2>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.17.6&#8243; _module_preset=&#8221;default&#8221; text_line_height=&#8221;25px&#8221; custom_padding=&#8221;|||20px|false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><span>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' ><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_custom\">(Required)<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/417#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_19\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>LinkedIn<\/label><div class='ginput_container'><input name='input_19' id='input_3_19' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_19'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>F\u00fcr folgenden Patienten ben\u00f6tige ich einen fach\u00e4rztlichen neurochirurgischen Rat:<\/strong><\/p><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Name*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>Vorname*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Geburtsdatum:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_3_10' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_10' class='gform_hidden' value='https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Telefon*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_3_14' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_3_13' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Adresse:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>Name Krankenkasse:<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_3_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_17'>VEKA Nummer:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_3_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>Zuweisung durch*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_3_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Wichtige Symptome: Bitte alle zutreffenden Antworten ankreuzen.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_6'><div class='gchoice gchoice_3_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Lumbalgie'  id='choice_3_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_1' id='label_3_6_1' class='gform-field-label gform-field-label--type-inline'>Lumbalgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Thorakalgie'  id='choice_3_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_2' id='label_3_6_2' class='gform-field-label gform-field-label--type-inline'>Thorakalgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='Zervikalgie'  id='choice_3_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_3' id='label_3_6_3' class='gform-field-label gform-field-label--type-inline'>Zervikalgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='Zervikobrachialgie'  id='choice_3_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_4' id='label_3_6_4' class='gform-field-label gform-field-label--type-inline'>Zervikobrachialgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='St\u00f6rung der Hirnnerven inkl. Epilepsie'  id='choice_3_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_5' id='label_3_6_5' class='gform-field-label gform-field-label--type-inline'>St\u00f6rung der Hirnnerven inkl. Epilepsie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.6' type='checkbox'  value='Lumboischialgie und\/oder Lumbofemoralgie'  id='choice_3_6_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_6' id='label_3_6_6' class='gform-field-label gform-field-label--type-inline'>Lumboischialgie und\/oder Lumbofemoralgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.7' type='checkbox'  value='Linke Seite haupts\u00e4chlich'  id='choice_3_6_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_7' id='label_3_6_7' class='gform-field-label gform-field-label--type-inline'>Linke Seite haupts\u00e4chlich<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.8' type='checkbox'  value='Rechte Seite haupts\u00e4chlich'  id='choice_3_6_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_8' id='label_3_6_8' class='gform-field-label gform-field-label--type-inline'>Rechte Seite haupts\u00e4chlich<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.9' type='checkbox'  value='Parese, Hyposensibiltit\u00e4t, Par\u00e4sthesie'  id='choice_3_6_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_9' id='label_3_6_9' class='gform-field-label gform-field-label--type-inline'>Parese, Hyposensibiltit\u00e4t, Par\u00e4sthesie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.11' type='checkbox'  value='Ein R\u00f6ntgenbild ap\/lat ist verf\u00fcgbar.'  id='choice_3_6_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_11' id='label_3_6_11' class='gform-field-label gform-field-label--type-inline'>Ein R\u00f6ntgenbild ap\/lat ist verf\u00fcgbar.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.12' type='checkbox'  value='Ein MRI ist verf\u00fcgbar.'  id='choice_3_6_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_12' id='label_3_6_12' class='gform-field-label gform-field-label--type-inline'>Ein MRI ist verf\u00fcgbar.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.13' type='checkbox'  value='Aktuell sind keine radiologischen Untersuchungen vorhanden, die j\u00fcnger als 3 Monate sind. (Falls noch nicht verf\u00fcgbar, werden diese von der Praxis Sailer veranlasst.)'  id='choice_3_6_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_13' id='label_3_6_13' class='gform-field-label gform-field-label--type-inline'>Aktuell sind keine radiologischen Untersuchungen vorhanden, die j\u00fcnger als 3 Monate sind. (Falls noch nicht verf\u00fcgbar, werden diese von der Praxis Sailer veranlasst.)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_4\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>Anfragenotizen:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_4' id='input_3_4' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Datenschutz<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_5'><div class='gchoice gchoice_3_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Ich akzeptiere die &lt;a href=&quot;https:\/\/rueckenmedizin.ch\/datenschutz\/&quot; target=&quot;_blank&quot;&gt;Datenschutzerkl\u00e4rung&lt;\/a&gt;'  id='choice_3_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_5_1' id='label_3_5_1' class='gform-field-label gform-field-label--type-inline'>Ich akzeptiere die <a href=\"https:\/\/rueckenmedizin.ch\/datenschutz\/\" target=\"_blank\">Datenschutzerkl\u00e4rung<\/a><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Bitte den Patienten aufbieten'  \/> <input type='hidden' name='gform_ajax' value='form_id=3&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=862c74d761a3cc06770d4622c8021787' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='2LeR16EljSR1O3UK+jWapn7qCFaLcXtytJxZB1MOOG\/wxsM\/Lj5cMLhcMK6AbQG3YdjfLGerSkIzFzOsJz7zxv0j\/ZrZ0K3MG4pCECdbMizEOeo=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJbXSIsImNhYzAyNWVjM2UzYzUyODVkY2YzNDcxMzIxYzFlOThlIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_3' id='gform_ajax_frame_3' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 3, 'https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_3').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_3');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_3').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_3').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_3').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_3').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_3').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_3').val();gformInitSpinner( 3, 'https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [3, current_page]);window['gf_submitting_3'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_3').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_3').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [3]);window['gf_submitting_3'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_3').text());}else{jQuery('#gform_3').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"3\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_3\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_3\";            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);\n<\/script>\n<\/span><\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Referring doctor<div class=\"et_pb_module lwp_divi_breadcrumbs lwp_divi_breadcrumbs_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"lwp-breadcrumbs\"> <span class=\"before\"><\/span> <span vocab=\"https:\/\/schema.org\/\" typeof=\"BreadcrumbList\"><span property=\"itemListElement\" typeof=\"ListItem\"><a property=\"item\" typeof=\"WebPage\" href=\"https:\/\/rueckenmedizin.ch\/en\/\" class=\"home\"><span property=\"name\">Homepage<\/span><\/a><meta property=\"position\" content=\"1\"><\/span> <span class=\"separator et-pb-icon\">&#x35;<\/span> <\/span><\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>Referral or request from doctor:\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_7' ><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_custom\">(Required)<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_7' id='gform_7'  action='\/en\/wp-json\/wp\/v2\/pages\/417#gf_7' data-formid='7' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_7_19\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_19'>Name<\/label><div class='ginput_container'><input name='input_19' id='input_7_19' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_7_19'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_7_7\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>I require specialist neurosurgical advice for the following patient::<\/strong><\/p><\/div><div id=\"field_7_8\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_8'>Surname*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_7_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_9\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_9'>Name*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_7_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_10\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_10'>Date of birth:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_7_10' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_7_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_10' class='gform_hidden' value='https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_7_14\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_14'>Telephone*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_7_14' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_13\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_13'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_7_13' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_7_15\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_15'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_7_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_16\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_16'>Name of health insurance provider:<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_7_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_17\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_17'>Health insurance card number:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_7_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_18\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_18'>Referred by*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_7_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Important symptoms: Please tick all that apply.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_6'><div class='gchoice gchoice_7_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Lumbar pain'  id='choice_7_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_1' id='label_7_6_1' class='gform-field-label gform-field-label--type-inline'>Lumbar pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Thoracic pain'  id='choice_7_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_2' id='label_7_6_2' class='gform-field-label gform-field-label--type-inline'>Thoracic pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='Cervical pain'  id='choice_7_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_3' id='label_7_6_3' class='gform-field-label gform-field-label--type-inline'>Cervical pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='Cervicobrachial pain'  id='choice_7_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_4' id='label_7_6_4' class='gform-field-label gform-field-label--type-inline'>Cervicobrachial pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='Disorder of the cranial nerves, including epilepsy'  id='choice_7_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_5' id='label_7_6_5' class='gform-field-label gform-field-label--type-inline'>Disorder of the cranial nerves, including epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.6' type='checkbox'  value='Lumbo-ischial pain and\/or lumbo-femoral pain'  id='choice_7_6_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_6' id='label_7_6_6' class='gform-field-label gform-field-label--type-inline'>Lumbo-ischial pain and\/or lumbo-femoral pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.7' type='checkbox'  value='Mainly left side'  id='choice_7_6_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_7' id='label_7_6_7' class='gform-field-label gform-field-label--type-inline'>Mainly left side<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.8' type='checkbox'  value='Mainly right side'  id='choice_7_6_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_8' id='label_7_6_8' class='gform-field-label gform-field-label--type-inline'>Mainly right side<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.9' type='checkbox'  value='Paresis, hyposensitivity, paraesthesia'  id='choice_7_6_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_9' id='label_7_6_9' class='gform-field-label gform-field-label--type-inline'>Paresis, hyposensitivity, paraesthesia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.11' type='checkbox'  value='An X-ray (ap\/lat) is available.'  id='choice_7_6_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_11' id='label_7_6_11' class='gform-field-label gform-field-label--type-inline'>An X-ray (ap\/lat) is available.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.12' type='checkbox'  value='An MRI is available.'  id='choice_7_6_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_12' id='label_7_6_12' class='gform-field-label gform-field-label--type-inline'>An MRI is available.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_6_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.13' type='checkbox'  value='There are currently no radiological examinations less than 3 months old. (If not yet available, these will be arranged by the Sailer practice)'  id='choice_7_6_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_6_13' id='label_7_6_13' class='gform-field-label gform-field-label--type-inline'>There are currently no radiological examinations less than 3 months old. (If not yet available, these will be arranged by the Sailer practice)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_4\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_4'>Enquiry notes:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_4' id='input_7_4' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Datenschutz<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_7_5'><div class='gchoice gchoice_7_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='I accept the &lt;a href=&quot;https:\/\/rueckenmedizin.ch\/en\/privacy-policy\/&quot; target=&quot;_blank&quot;&gt;Privacy Policy&lt;\/a&gt;'  id='choice_7_5_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_5_1' id='label_7_5_1' class='gform-field-label gform-field-label--type-inline'>I accept the <a href=\"https:\/\/rueckenmedizin.ch\/en\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_7' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Please schedule an appointment with the patient.'  \/> <input type='hidden' name='gform_ajax' value='form_id=7&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=e1938d96c36a6f420f2cc5932eb83cb1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_7' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_7' id='gform_theme_7' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_7' id='gform_style_settings_7' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_7' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='7' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='Fu+TerU86ceOBcy4WDdn+IwxL\/gVxVrCWgd80j3oKPwPAwvgOzY0OJgevRV\/ubNeL\/uGSDi3LyM+KF\/jDi+3EjNIkgeuefsZ9dmnfo5ITW6qGDw=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_7' value='WyJbXSIsImNhYzAyNWVjM2UzYzUyODVkY2YzNDcxMzIxYzFlOThlIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_7' id='gform_target_page_number_7' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_7' id='gform_source_page_number_7' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_7' id='gform_ajax_frame_7' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 7, 'https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_7').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_7');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_7').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_7').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_7').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_7').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_7').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_7').val();gformInitSpinner( 7, 'https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [7, current_page]);window['gf_submitting_7'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_7').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_7').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [7]);window['gf_submitting_7'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_7').text());}else{jQuery('#gform_7').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"7\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_7\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_7\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_7\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 7, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\nZuweiser\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' ><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_custom\">(Required)<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/en\/wp-json\/wp\/v2\/pages\/417#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_19\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_19'>Phone<\/label><div class='ginput_container'><input name='input_19' id='input_3_19' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_19'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>F\u00fcr folgenden Patienten ben\u00f6tige ich einen fach\u00e4rztlichen neurochirurgischen Rat:<\/strong><\/p><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Name*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>Vorname*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Geburtsdatum:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_10' id='input_3_10' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_3_10_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_10_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_10' class='gform_hidden' value='https:\/\/rueckenmedizin.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_14\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Telefon*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_14' id='input_3_14' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_13\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_13'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_13' id='input_3_13' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Adresse:<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_3_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>Name Krankenkasse:<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_3_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_17'>VEKA Nummer:<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_3_17' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>Zuweisung durch*:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_3_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_6\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Wichtige Symptome: Bitte alle zutreffenden Antworten ankreuzen.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_custom\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_6'><div class='gchoice gchoice_3_6_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.1' type='checkbox'  value='Lumbalgie'  id='choice_3_6_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_1' id='label_3_6_1' class='gform-field-label gform-field-label--type-inline'>Lumbalgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.2' type='checkbox'  value='Thorakalgie'  id='choice_3_6_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_2' id='label_3_6_2' class='gform-field-label gform-field-label--type-inline'>Thorakalgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.3' type='checkbox'  value='Zervikalgie'  id='choice_3_6_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_3' id='label_3_6_3' class='gform-field-label gform-field-label--type-inline'>Zervikalgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.4' type='checkbox'  value='Zervikobrachialgie'  id='choice_3_6_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_4' id='label_3_6_4' class='gform-field-label gform-field-label--type-inline'>Zervikobrachialgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.5' type='checkbox'  value='St\u00f6rung der Hirnnerven inkl. Epilepsie'  id='choice_3_6_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_5' id='label_3_6_5' class='gform-field-label gform-field-label--type-inline'>St\u00f6rung der Hirnnerven inkl. Epilepsie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.6' type='checkbox'  value='Lumboischialgie und\/oder Lumbofemoralgie'  id='choice_3_6_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_6' id='label_3_6_6' class='gform-field-label gform-field-label--type-inline'>Lumboischialgie und\/oder Lumbofemoralgie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.7' type='checkbox'  value='Linke Seite haupts\u00e4chlich'  id='choice_3_6_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_7' id='label_3_6_7' class='gform-field-label gform-field-label--type-inline'>Linke Seite haupts\u00e4chlich<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.8' type='checkbox'  value='Rechte Seite haupts\u00e4chlich'  id='choice_3_6_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_8' id='label_3_6_8' class='gform-field-label gform-field-label--type-inline'>Rechte Seite haupts\u00e4chlich<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.9' type='checkbox'  value='Parese, Hyposensibiltit\u00e4t, Par\u00e4sthesie'  id='choice_3_6_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_9' id='label_3_6_9' class='gform-field-label gform-field-label--type-inline'>Parese, Hyposensibiltit\u00e4t, Par\u00e4sthesie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.11' type='checkbox'  value='Ein R\u00f6ntgenbild ap\/lat ist verf\u00fcgbar.'  id='choice_3_6_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_11' id='label_3_6_11' class='gform-field-label gform-field-label--type-inline'>Ein R\u00f6ntgenbild ap\/lat ist verf\u00fcgbar.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.12' type='checkbox'  value='Ein MRI ist verf\u00fcgbar.'  id='choice_3_6_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_12' id='label_3_6_12' class='gform-field-label gform-field-label--type-inline'>Ein MRI ist verf\u00fcgbar.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_6_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_6.13' type='checkbox'  value='Aktuell sind keine radiologischen Untersuchungen vorhanden, die j\u00fcnger als 3 Monate sind. (Falls noch nicht verf\u00fcgbar, werden diese von der Praxis Sailer veranlasst.)'  id='choice_3_6_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_6_13' id='label_3_6_13' class='gform-field-label gform-field-label--type-inline'>Aktuell sind keine radiologischen Untersuchungen vorhanden, die j\u00fcnger als 3 Monate sind. 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