{"id":215,"date":"2023-07-26T13:14:47","date_gmt":"2023-07-26T11:14:47","guid":{"rendered":"https:\/\/teledoctor.pl\/become-a-patient\/"},"modified":"2023-07-28T08:16:44","modified_gmt":"2023-07-28T06:16:44","slug":"register-now","status":"publish","type":"page","link":"https:\/\/teledoctor.pl\/en\/register-now\/","title":{"rendered":"Become a Patient"},"content":{"rendered":"<div class=\"stepper-wrapper\">\n      <div class=\"stepper-item active\">\n        <div class=\"step-counter\">1<\/div>\n        <div class=\"step-name\">Fill in the form<\/div>\n      <\/div>\n      <div class=\"stepper-item\">\n        <div class=\"step-counter\">2<\/div>\n        <div class=\"step-name\">Sign and send the declaration<\/div>\n      <\/div>\n      <div class=\"stepper-item\">\n        <div class=\"step-counter\">3<\/div>\n        <div class=\"step-name\">Make an appointment<\/div>\n      <\/div>\n    <\/div><form action=\"\/en\/wp-json\/wp\/v2\/pages\/215\" method=\"post\" class=\"form-declarations\"><div class=\"row\"><div class=\"col-md-6\"><div class=\"form-row\"><label for=\"d_name\">Name: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_name\" id=\"d_name\" required placeholder=\"Name\"><\/div><\/div><div class=\"col-md-6\"><div class=\"form-row\"><label for=\"d_surname\">Surname: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_surname\" id=\"d_surname\" required  placeholder=\"Surname\"><\/div><\/div><\/div><div class=\"row\"><div class=\"col-md-5\"><div class=\"form-row\"><label for=\"d_pesel\">PESEL: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_pesel\" id=\"d_pesel\" required placeholder=\"PESEL number\"><\/div><\/div><div class=\"col-md-4\"><div class=\"form-row\"><label for=\"d_birthday\">Birthday date: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_birthday\" id=\"d_birthday\" required><\/div><\/div><div class=\"col-md-3\"><div class=\"form-row\"><label for=\"d_sex\">Sex: <span class=\"required\">*<\/span><\/label><select name=\"d_sex\" id=\"d_sex\" required placeholder=\"Choose\">\n       <option value=\"\" disabled selected>Choose<\/option>\n             <option>Woman<\/option>\n             <option>Man<\/option>\n         <\/select><\/div><\/div><\/div><div class=\"row\"><div class=\"col-md-6\"><div class=\"form-row\"><label for=\"d_phone\">Phone number: <span class=\"required\">**<\/span><\/label><input type=\"text\" name=\"d_phone\" id=\"d_phone\"><\/div><\/div><div class=\"col-md-6\"><div class=\"form-row\"><label for=\"d_mail\">Email Address: <span class=\"required\">**<\/span><\/label><input type=\"email\" name=\"d_mail\" id=\"d_mail\" placeholder=\"Email Address\"><\/div><\/div><\/div><div class=\"row\"><div class=\"col-md-4\"><div class=\"form-row\"><label for=\"d_street\">Street: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_street\" id=\"d_street\" required placeholder=\"Street\"><\/div><\/div><div class=\"col-md-3\"><div class=\"form-row\"><label for=\"d_address\">House \/ apartment number: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_address\" id=\"d_address\" required placeholder=\"Building number* \/ Apartment number\"><\/div><\/div><div class=\"col-md-2\"><div class=\"form-row\"><label for=\"d_postcode\">Zip code: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_postcode\" id=\"d_postcode\" required><\/div><\/div><div class=\"col-md-3\"><div class=\"form-row\"><label for=\"d_city\">City: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"d_city\" id=\"d_city\" required placeholder=\"City\"><\/div><\/div><\/div><div class=\"row\"><div class=\"col-md-6\"><div class=\"form-row\"><label for=\"d_changetime\">W bie\u017c\u0105cym roku kalendarzowym dokonuj\u0119 wyboru: <span class=\"required\">*<\/span><\/label><select name=\"d_changetime\" id=\"d_changetime\" required>\n             <option value=\"first-time\">For the first time or for the second time<\/option>\n             <option value=\"more-time\">for the third time and again<\/option>\n         <\/select><\/div><\/div><div class=\"col-md-6\"><div class=\"form-row\"><label for=\"d_clinic\">Choosing a POZ clinic: <span class=\"required\">*<\/span><\/label><select name=\"d_clinic\" id=\"d_clinic\" required><option value=\"1\">Przychodnia Teledoctor, ul. Zielona 29, \u0141\u00f3d\u017a<\/option><\/select><\/div><\/div><\/div><div class=\"row\"><div class=\"col-md-12\"><div class=\"form-changed-options hidden-field\"><fieldset>\n       <legend>If the choice is made for the third or subsequent time in the current calendar year, it should be indicated whether the reason for the choice is:  <span class=\"required\">*<\/span><\/legend>\n    <div class=\"checkbox-form\">\n      <input type=\"radio\" id=\"form-changed-options-1\" name=\"form-changed-option\" value=\"1\">\n      <label for=\"form-changed-options-1\">Choosing a POZ clinicokoliczno\u015b\u0107 okre\u015blona w art. 9 ust. 5 ustawy z dnia 27 pa\u017adziernika 2017 r. o podstawowej opiece zdrowotnej:<br>\n      <ul>\n      <li>change of residence<\/li>\n      <li>cessation of providing health care services by a selected healthcare provider, a primary care physician at a selected healthcare provider<\/li>\n      <li>reaching the age of 18 by the beneficiary, when the primary care physician is a doctor with a 1st or 2nd degree specialization or the title of specialist in paediatrics<\/li>\n      <li>for other reasons on the part of the service provider<br><\/li>\n      <\/ul><\/label>\n    <\/div><div class=\"checkbox-form\">\n      <input type=\"radio\" id=\"form-changed-options-2\" name=\"form-changed-option\" value=\"2\">\n      <label for=\"form-changed-options-2\">Another circumstance<\/label>\n    <\/div><\/div>\n \n \n <\/fieldset><\/div><\/div><div class=\"row\">\n <div class=\"col-md-12\">\n    <a class=\"add-representative\">Add legal representative<\/a><br>\n    <span class=\"text-infoblock\">(In the case where the beneficiary is a minor or completely incapacitated)<\/span>\n <\/div><div class=\" col-md-12\"><div class=\"representative-block hidden-field\">\n <legend>Data concerning the legal representative:<\/legend>\n <div class=\"row\"><div class=\"col-md-4\"><div class=\"form-row\"><input type=\"text\" name=\"is_represent\" id=\"is_represent\" value=\"no-represented\" style=\"display: none;\"><label for=\"rep_name\">Name: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"rep_name\" id=\"rep_name\"><\/div><\/div><div class=\"col-md-4\"><div class=\"form-row\"><label for=\"rep_surname\">Surname: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"rep_surname\" id=\"rep_surname\"><\/div><\/div><div class=\"col-md-4\"><div class=\"form-row\"><label for=\"rep_phone\">Phone number: <span class=\"optional\">**<\/span><\/label><input type=\"text\" name=\"rep_phone\" id=\"rep_phone\"><\/div><\/div><div class=\"col-md-4\"><div class=\"form-row\"><label for=\"rep_street\">Street: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"rep_street\" id=\"rep_street\"><\/div><\/div><div class=\"col-md-3\"><div class=\"form-row\"><label for=\"rep_address\">House \/ apartment number: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"rep_address\" id=\"rep_address\"><\/div><\/div><div class=\"col-md-2\"><div class=\"form-row\"><label for=\"rep_postcode\">Zip code: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"rep_postcode\" id=\"rep_postcode\"><\/div><\/div><div class=\"col-md-3\"><div class=\"form-row\"><label for=\"rep_city\">City: <span class=\"required\">*<\/span><\/label><input type=\"text\" name=\"rep_city\" id=\"rep_city\"><\/div><\/div>\n    \n    \n    <\/div>\n    <\/div>\n <\/div><div class=\"col-md-12\"><div class=\"accepts-row\">\n \n<label for=\"accept_rules\"> <input type=\"checkbox\" id=\"accept_rules\" name=\"accept_rules\" value=\"accept_rules\" required> <strong>I confirm the correctness of the entered data.<span class=\"required\">*<\/span><\/strong> <br>Jednocze\u015bnie wyra\u017cam zgod\u0119 na przetwarzanie moich danych osobowych w celu wygenerowania deklaracji wyboru \u015bwiadczeniodawcy udzielaj\u0105cego \u015bwiadcze\u0144 z zakresu Podstawowej Opieki Zdrowotnej oraz Lekarza, Piel\u0119gniarki i Po\u0142o\u017cnej Podstawowej Opieki Zdrowotnej. Informujemy, \u017ce przes\u0142ane dane nie s\u0105 wykorzystywane w inny spos\u00f3b ni\u017c tylko do wype\u0142nienia deklaracji i wpisania danych w karcie Pacjenta wybranej plac\u00f3wki POZ.<\/label><\/div><\/div><div class=\"col-md-12\"><div class=\"form-legends\">\n <p>Legenda:<\/p>\n <span class=\"required\">*<\/span> - Required field<br>\n <span class=\"optional\">**<\/span> - Mandatory field, providing contact details will allow the doctor to contact the patient in order to conduct teleconsultation, as well as complete the registration correctly<\/div><\/div><div class=\"col-md-12\"><div class=\"form-row\"><input type=\"submit\" name=\"d-submitted-pdf\" value=\"Download the declaration and sign it\"><input type=\"hidden\" name=\"recaptcha_token\" id=\"recaptchaToken\"><\/div><\/div><\/div><\/form><!-- reCAPTCHA v3 \u2013 token generowany przy wys\u0142aniu formularza (nie przy \u0142adowaniu strony) -->\n      <script src=\"https:\/\/www.google.com\/recaptcha\/api.js?render=6LfTTCArAAAAABSHqj6UxMQVz09z8YkkO8M0pzoE\"><\/script>\n      <script>\n      (function() {\n         var form = document.querySelector(\"form.form-declarations\");\n         var tokenInput = document.getElementById(\"recaptchaToken\");\n         var siteKey = \"6LfTTCArAAAAABSHqj6UxMQVz09z8YkkO8M0pzoE\";\n         if (!form || !tokenInput) return;\n         form.addEventListener(\"submit\", function(e) {\n            if (tokenInput.value) return;\n            e.preventDefault();\n            var f = form;\n            if (window.grecaptcha && window.grecaptcha.execute) {\n               grecaptcha.ready(function() {\n                  grecaptcha.execute(siteKey, { action: \"declaration_form\" }).then(function(token) {\n                     tokenInput.value = token;\n                     var hid = document.createElement(\"input\");\n                     hid.type = \"hidden\";\n                     hid.name = \"d-submitted-pdf\";\n                     hid.value = \"1\";\n                     f.appendChild(hid);\n                     f.submit();\n                  }).catch(function() {\n                     f.submit();\n                  });\n               });\n            } else {\n               f.submit();\n            }\n         });\n      })();\n      <\/script>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-215","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.4 - 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