{"id":36,"date":"2017-01-30T19:42:18","date_gmt":"2017-01-30T18:42:18","guid":{"rendered":"http:\/\/floris-acupunctuur.nl\/site\/?page_id=36"},"modified":"2021-07-12T14:40:31","modified_gmt":"2021-07-12T12:40:31","slug":"inschrijven-nieuwe-patient","status":"publish","type":"page","link":"https:\/\/floris-acupunctuur.nl\/site\/inschrijven-nieuwe-patient\/","title":{"rendered":"Inschrijven nieuwe patient"},"content":{"rendered":"<div data-test='contact-form'\n\t\t\tid='contact-form-36'\n\t\t\tclass='wp-block-jetpack-contact-form-container '\n\t\t\tdata-wp-interactive='jetpack\/form' data-wp-context='{\"formId\":\"36\",\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\",\"showErrors\":false,\"errors\":[],\"fields\":[],\"isMultiStep\":false,\"useAjax\":true,\"submissionData\":null,\"formattedSubmissionData\":[],\"submissionSuccess\":false,\"submissionError\":null,\"elementId\":\"jp-form-06315fdacb29e9745507fa73c7387a056141dac4\",\"isSingleInputForm\":false}'\n\t\t\tdata-wp-watch--scroll-to-wrapper=\"callbacks.scrollToWrapper\"\n\t\t>\n<div class=\"contact-form-submission contact-form-ajax-submission\" data-wp-class--submission-success=\"context.submissionSuccess\"><p class=\"go-back-message\"><a class=\"link\" role=\"button\" tabindex=\"0\" data-wp-on--click=\"actions.goBack\" href=\"\/site\/wp-json\/wp\/v2\/pages\/36\">Terugkeren<\/a><\/p><h4 id=\"contact-form-success-header\">Je bericht is verzonden<\/h4>\n\n<template data-wp-each--submission=\"context.formattedSubmissionData\">\n\t\t\t\t\t<div class=\"jetpack_forms_contact-form-success-summary\">\n\t\t\t\t\t\t<div class=\"field-name\" data-wp-text=\"context.submission.label\" data-wp-bind--hidden=\"!context.submission.label\"><\/div>\n\t\t\t\t\t\t<div class=\"field-value\" data-wp-text=\"context.submission.value\"><\/div>\n\t\t\t\t\t\t<div class=\"field-images\" data-wp-bind--hidden=\"!context.submission.images\">\n\t\t\t\t\t\t\t<template data-wp-each--image=\"context.submission.images\">\n\t\t\t\t\t\t\t\t<figure class=\"field-image\" data-wp-class--is-empty=\"!context.image\">\n\t\t\t\t\t\t\t\t\t<img data-wp-bind--src=\"context.image\" data-wp-bind--hidden=\"!context.image\" \/>\n\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"data:image\/gif;base64,R0lGODlhAQABAAD\/ACwAAAAAAQABAAACADs=\" data-wp-bind--hidden=\"context.image\" \/>\n\t\t\t\t\t\t\t\t<\/figure>\n\t\t\t\t\t\t\t<\/template>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/template><\/div><form action='https:\/\/floris-acupunctuur.nl\/site\/inschrijven-nieuwe-patient\/'\n\t\t\t\tid='jp-form-06315fdacb29e9745507fa73c7387a056141dac4'\n\t\t\t\tmethod='post'\n\t\t\t\tclass='contact-form commentsblock' aria-label=\"Inschrijven nieuwe patient\"\n\t\t\t\tdata-wp-on--submit=\"actions.onFormSubmit\"\n\t\t\t\tdata-wp-on--reset=\"actions.onFormReset\"\n\t\t\t\tdata-wp-class--submission-success=\"context.submissionSuccess\"\n\t\t\t\tdata-wp-class--is-first-step=\"state.isFirstStep\"\n\t\t\t\tdata-wp-class--is-last-step=\"state.isLastStep\"\n\t\t\t\tdata-wp-class--is-ajax-form=\"context.useAjax\"\n\t\t\t\tnovalidate >\n<input type='hidden' name='jetpack_contact_form_jwt' value='eyJ0eXAiOiJKV1QiLCJhbGciOiJIUzI1NiJ9.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_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.dKf3zCZ88F9wbAJGPC1vmijiRn_TR2m6vdTo2bxoh28' \/>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-voornaam\",\"fieldType\":\"name\",\"fieldLabel\":\"Voornaam:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-name-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-voornaam' class=\"grunion-field-label name\" >Voornaam:<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-voornaam'\n\t\t\t\t\tid='g36-voornaam'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-voornaam-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='name  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-voornaam-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-voornaam-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-initialen\",\"fieldType\":\"name\",\"fieldLabel\":\"Initialen:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-name-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-initialen' class=\"grunion-field-label name\" >Initialen:<\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-initialen'\n\t\t\t\t\tid='g36-initialen'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-initialen-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='name  grunion-field' \n\t\t\t\t\t \/>\n \n\t\t\t<div id=\"g36-initialen-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-initialen-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-achternaam\",\"fieldType\":\"name\",\"fieldLabel\":\"Achternaam:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-name-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-achternaam' class=\"grunion-field-label name\" >Achternaam:<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-achternaam'\n\t\t\t\t\tid='g36-achternaam'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-achternaam-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='name  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-achternaam-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-achternaam-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-geslacht\",\"fieldType\":\"select\",\"fieldLabel\":\"Geslacht: \",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-select-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-geslacht' class=\"grunion-field-label select\" >Geslacht: <span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<div class=\"contact-form__select-wrapper select  grunion-field\"  style=''>\t<span class='contact-form__select-element-wrapper'><select name='g36-geslacht' id='g36-geslacht' required aria-required='true' data-wp-on--change='actions.onFieldChange' data-wp-bind--aria-invalid='state.fieldHasErrors' >\n\t\t<option value='Man'>Man<\/option>\n\t\t<option value='Vrouw'>Vrouw<\/option>\n\t<\/select><span class='jetpack-field-dropdown__icon'><\/span><\/span>\n<\/div>\n\n\t\t\t<div id=\"g36-geslacht-select-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-geslacht-select-error-message\"><\/span>\n\t\t\t<\/div>\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-geboortedatum\",\"fieldType\":\"text\",\"fieldLabel\":\"Geboortedatum:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-geboortedatum' class=\"grunion-field-label text\" >Geboortedatum:<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-geboortedatum'\n\t\t\t\t\tid='g36-geboortedatum'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-geboortedatum-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-geboortedatum-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-geboortedatum-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-adres\",\"fieldType\":\"text\",\"fieldLabel\":\"Adres:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-adres' class=\"grunion-field-label text\" >Adres:<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-adres'\n\t\t\t\t\tid='g36-adres'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-adres-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-adres-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-adres-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-postcode\",\"fieldType\":\"text\",\"fieldLabel\":\"Postcode:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-postcode' class=\"grunion-field-label text\" >Postcode:<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-postcode'\n\t\t\t\t\tid='g36-postcode'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-postcode-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-postcode-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-postcode-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-plaats\",\"fieldType\":\"text\",\"fieldLabel\":\"Plaats:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-plaats' class=\"grunion-field-label text\" >Plaats:<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-plaats'\n\t\t\t\t\tid='g36-plaats'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-plaats-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-plaats-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-plaats-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-telefoonnummer\",\"fieldType\":\"text\",\"fieldLabel\":\"Telefoonnummer: \",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-telefoonnummer' class=\"grunion-field-label text\" >Telefoonnummer: <span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-telefoonnummer'\n\t\t\t\t\tid='g36-telefoonnummer'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-telefoonnummer-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-telefoonnummer-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-telefoonnummer-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-mobiel\",\"fieldType\":\"text\",\"fieldLabel\":\"Mobiel:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-mobiel' class=\"grunion-field-label text\" >Mobiel:<\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-mobiel'\n\t\t\t\t\tid='g36-mobiel'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-mobiel-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\t \/>\n \n\t\t\t<div id=\"g36-mobiel-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-mobiel-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-emailadres\",\"fieldType\":\"text\",\"fieldLabel\":\"E-Mail adres:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-emailadres' class=\"grunion-field-label text\" >E-Mail adres:<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-emailadres'\n\t\t\t\t\tid='g36-emailadres'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-emailadres-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\trequired='true' aria-required='true'  \/>\n \n\t\t\t<div id=\"g36-emailadres-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-emailadres-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-aanvullendverzekerd\",\"fieldType\":\"select\",\"fieldLabel\":\"Aanvullend verzekerd?: \",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-select-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-aanvullendverzekerd' class=\"grunion-field-label select\" >Aanvullend verzekerd?: <span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<div class=\"contact-form__select-wrapper select  grunion-field\"  style=''>\t<span class='contact-form__select-element-wrapper'><select name='g36-aanvullendverzekerd' id='g36-aanvullendverzekerd' required aria-required='true' data-wp-on--change='actions.onFieldChange' data-wp-bind--aria-invalid='state.fieldHasErrors' >\n\t\t<option value='Ja'>Ja<\/option>\n\t\t<option value='Nee'>Nee<\/option>\n\t<\/select><span class='jetpack-field-dropdown__icon'><\/span><\/span>\n<\/div>\n\n\t\t\t<div id=\"g36-aanvullendverzekerd-select-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-aanvullendverzekerd-select-error-message\"><\/span>\n\t\t\t<\/div>\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-zojawelke\",\"fieldType\":\"text\",\"fieldLabel\":\"Zo ja, welke:\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-text-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='g36-zojawelke' class=\"grunion-field-label text\" >Zo ja, welke:<\/label>\n<input\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='g36-zojawelke'\n\t\t\t\t\tid='g36-zojawelke'\n\t\t\t\t\tvalue=''\n\n\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\tdata-wp-bind--value='state.getFieldValue'\n\t\t\t\t\taria-errormessage='g36-zojawelke-text-error-message'\n\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\n\t\t\t\t\tclass='text  grunion-field' \n\t\t\t\t\t \/>\n \n\t\t\t<div id=\"g36-zojawelke-text-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-zojawelke-text-error-message\"><\/span>\n\t\t\t<\/div> \n\t<\/div>\n\n<div style=\"\"  data-wp-interactive=\"jetpack\/form\" data-wp-context='{\"fieldId\":\"g36-omschrijvingklachten\",\"fieldType\":\"textarea\",\"fieldLabel\":\"Omschrijving klachten\",\"fieldValue\":\"\",\"fieldPlaceholder\":\"\",\"fieldIsRequired\":\"1\",\"fieldErrorMessage\":\"\",\"fieldExtra\":[],\"formHash\":\"06315fdacb29e9745507fa73c7387a056141dac4\"}'  class='grunion-field-textarea-wrap grunion-field-wrap'  data-wp-init='callbacks.initializeField' data-wp-on--jetpack-form-reset='callbacks.initializeField' >\n<label\n\t\t\t\tfor='contact-form-comment-g36-omschrijvingklachten' class=\"grunion-field-label textarea\" >Omschrijving klachten<span class=\"grunion-label-required\" aria-hidden=\"true\">(vereist)<\/span><\/label>\n<textarea\n\t\t                style=''\n\t\t                name='g36-omschrijvingklachten'\n\t\t                id='contact-form-comment-g36-omschrijvingklachten'\n\t\t                rows='20'\n\t\t\t\t\t\tdata-wp-text='state.getFieldValue'\n\t\t\t\t\t\tdata-wp-on--input='actions.onFieldChange'\n\t\t\t\t\t\tdata-wp-on--blur='actions.onFieldBlur'\n\t\t\t\t\t\tdata-wp-class--has-value='state.hasFieldValue'\n\t\t\t\t\t\tdata-wp-bind--aria-invalid='state.fieldHasErrors'\n\t\t\t\t\t\taria-errormessage='g36-omschrijvingklachten-textarea-error-message'\n\t\t\t\t\t\tclass='textarea  grunion-field'  required aria-required='true'><\/textarea>\n \n\t\t\t<div id=\"g36-omschrijvingklachten-textarea-error\" class=\"contact-form__input-error\" data-wp-class--has-errors=\"state.fieldHasErrors\">\n\t\t\t\t<span class=\"contact-form__warning-icon\">\n\t\t\t\t\t<svg width=\"16\" height=\"16\" viewBox=\"0 0 16 16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n\t\t\t\t\t\t<path d=\"M8.50015 11.6402H7.50015V10.6402H8.50015V11.6402Z\" \/>\n\t\t\t\t\t\t<path d=\"M7.50015 9.64018H8.50015V6.30684H7.50015V9.64018Z\" \/>\n\t\t\t\t\t\t<path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M6.98331 3.0947C7.42933 2.30177 8.57096 2.30177 9.01698 3.09469L13.8771 11.7349C14.3145 12.5126 13.7525 13.4735 12.8602 13.4735H3.14004C2.24774 13.4735 1.68575 12.5126 2.12321 11.7349L6.98331 3.0947ZM8.14541 3.58496C8.08169 3.47168 7.9186 3.47168 7.85488 3.58496L2.99478 12.2251C2.93229 12.3362 3.01257 12.4735 3.14004 12.4735H12.8602C12.9877 12.4735 13.068 12.3362 13.0055 12.2251L8.14541 3.58496Z\" \/>\n\t\t\t\t\t<\/svg>\n\t\t\t\t\t<span class=\"visually-hidden\">Waarschuwing<\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<span data-wp-text=\"state.errorMessage\" id=\"g36-omschrijvingklachten-textarea-error-message\"><\/span>\n\t\t\t<\/div>\n\t<\/div>\n\t<p class='contact-submit'>\n<div class=\"contact-form__error\" data-wp-class--show-errors=\"state.showFormErrors\"><span class=\"contact-form__warning-icon\"><span class=\"visually-hidden\">Waarschuwing.<\/span><i aria-hidden=\"true\"><\/i><\/span>\n\t\t\t\t<span data-wp-text=\"state.getFormErrorMessage\"><\/span>\n\t\t\t\t<ul>\n\t\t\t\t<template data-wp-each=\"state.getErrorList\" data-wp-key=\"context.item.id\">\n\t\t\t\t\t<li><a data-wp-bind--href=\"context.item.anchor\" data-wp-on--click=\"actions.scrollIntoView\" data-wp-text=\"context.item.label\"><\/a><\/li>\n\t\t\t\t<\/template>\n\t\t\t\t<\/ul><\/div><div class=\"contact-form__error\" data-wp-class--show-errors=\"state.showSubmissionError\" data-wp-text=\"context.submissionError\"><\/div>\t\t<button type='submit' class='pushbutton-wide'>Verzenden<\/button>\t\t<input type='hidden' name='contact-form-id' value='36' \/>\n\t\t<input type='hidden' name='action' value='grunion-contact-form' \/>\n\t\t<input type='hidden' name='contact-form-hash' value='06315fdacb29e9745507fa73c7387a056141dac4' \/>\n\t<\/p>\n<p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"42\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"","meta":{"advanced_seo_description":"","jetpack_seo_html_title":"","jetpack_seo_noindex":false,"jetpack_post_was_ever_published":false,"footnotes":""},"class_list":["post-36","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/P8lIfq-A","jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/pages\/36","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/comments?post=36"}],"version-history":[{"count":12,"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/pages\/36\/revisions"}],"predecessor-version":[{"id":7413,"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/pages\/36\/revisions\/7413"}],"wp:attachment":[{"href":"https:\/\/floris-acupunctuur.nl\/site\/wp-json\/wp\/v2\/media?parent=36"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}