{"id":79639,"date":"2025-03-31T21:56:19","date_gmt":"2025-03-31T19:56:19","guid":{"rendered":"https:\/\/furstnerdentistry.hu\/?page_id=79639"},"modified":"2025-03-31T22:08:04","modified_gmt":"2025-03-31T20:08:04","slug":"registracio","status":"publish","type":"page","link":"https:\/\/furstnerdentistry.hu\/en\/registracio\/","title":{"rendered":"Registration"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.17.3&#8243; _module_preset=&#8221;default&#8221; use_background_color_gradient=&#8221;on&#8221; background_color_gradient_stops=&#8221;rgba(255,255,255,0.55) 0%|rgba(239,239,239,0.55) 100%&#8221; background_color_gradient_overlays_image=&#8221;on&#8221; background_enable_pattern_style=&#8221;on&#8221; background_pattern_style=&#8221;tufted&#8221; background_pattern_color=&#8221;#215E8D&#8221; background_pattern_size=&#8221;custom&#8221; background_pattern_width=&#8221;36px&#8221; background_pattern_height=&#8221;0px&#8221; 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da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;4.23&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.23&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; header_text_color=&#8221;#215E8D&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243; admin_label=&#8221;Regisztr\u00e1ci\u00f3&#8221;]<\/p>\n<h1 style=\"text-align: center;\">Registration<\/h1>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; admin_label=&#8221;%91fluentform id=%2216%22%93&#8243; sticky_enabled=&#8221;0&#8243;]<\/p>\n<div class='fluentform ff-default fluentform_wrapper_16 ffs_custom_wrap'><form data-form_id=\"16\" id=\"fluentform_16\" class=\"frm-fluent-form fluent_form_16 ff-el-form-top ff_form_instance_16_1 ff-form-loading ff-form-has-steps ffs_custom\" data-form_instance=\"ff_form_instance_16_1\" method=\"POST\" action=\"\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Patient registration (#16)<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_16_item_sf\" aria-label=\"Notify\">\n                    Notify                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_16__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_16_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='79639' \/><input type=\"hidden\" id=\"_fluentform_16_fluentformnonce\" name=\"_fluentform_16_fluentformnonce\" value=\"18ca3f6271\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/jogszeruonlinejelenlet_jijililjlililjliljliljlijliljlijilllijilljijliljilljllljliljlijlljlijllilljlllijijlljilljlijiljijlijlilililjlillljliljliljlijljijlliljlijijllijililjliljililjliljlijiljiljli\/wp\/v2\/pages\/79639\" \/><div class='ff-step-container' data-name=\"step_start-16_14\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div class='ff-step-header'><ul class='ff-step-titles'><li class='ff_active'><span>Identification<\/span><\/li><li><span>Contact<\/span><\/li><li><span>Treatment<\/span><\/li><li><span>Billing<\/span><\/li><li><span>Time to treatment<\/span><\/li><li><span>Related<\/span><\/li><\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-16_14\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group center infoBlock ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Please indicate whether you are the patient or filling in the form on behalf of someone else.\">Please indicate whether you are the patient or filling in the form on behalf of someone else.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for=\"kerjuk_jelolje_ki_a_paciens_daf2f9d9e25a211070a95d95e3b9b5d6\"><input  type=\"radio\" name=\"kerjuk_jelolje_ki_a_paciens\" data-name=\"kerjuk_jelolje_ki_a_paciens\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" tabindex=\"1\" value=\"\u00c9n vagyok a p\u00e1ciens\"  id='kerjuk_jelolje_ki_a_paciens_daf2f9d9e25a211070a95d95e3b9b5d6' aria-label='I am the patient' aria-invalid='false' aria-required=\"false\"> <span>I am the patient<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"kerjuk_jelolje_ki_a_paciens_667d4c1518c6a9a1d3d898d04c7f570d\"><input  type=\"radio\" name=\"kerjuk_jelolje_ki_a_paciens\" data-name=\"kerjuk_jelolje_ki_a_paciens\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"M\u00e1s nev\u00e9ben t\u00f6lt\u00f6m ki (pl. gyermek, hozz\u00e1tartoz\u00f3)\"  id='kerjuk_jelolje_ki_a_paciens_667d4c1518c6a9a1d3d898d04c7f570d' aria-label='I am filling in on behalf of someone else (e.g. child, relative)' aria-invalid='false' aria-required=\"false\"> <span>I am filling in on behalf of someone else (e.g. child, relative)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-16_1\" ><h6>Identification and declaration of the person entitled<\/h6><\/div><div data-type=\"name-element\" data-name=\"jrsz_neve\" class=\"has-conditions  ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_jrsz_neve_first_name_' >Last name of the person entitled<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"jrsz_neve[first_name]\" id=\"ff_16_jrsz_neve_first_name_\" class=\"ff-el-form-control\" placeholder=\"Last name\" tabindex=\"2\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_jrsz_neve_last_name_' >First name of the person entitled<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"jrsz_neve[last_name]\" id=\"ff_16_jrsz_neve_last_name_\" class=\"ff-el-form-control\" placeholder=\"First name\" tabindex=\"3\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_jrsz_szuletesi_ideje' aria-label=\"Eligible person&#039;s date of birth\">Eligible person's date of birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Jogosults\u00e1ggal rendelkez\u0151 szem\u00e9ly sz\u00fclet\u00e9si ideje Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='Y-m-d' type=\"text\" name=\"jrsz_szuletesi_ideje\" id=\"ff_16_jrsz_szuletesi_ideje\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date of birth\" data-name=\"jrsz_szuletesi_ideje\" tabindex=\"4\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_jrsz_szuletesi_hely' aria-label=\"Place of birth of the beneficiary\">Place of birth of the beneficiary<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"jrsz_szuletesi_hely\" class=\"ff-el-form-control\" data-name=\"jrsz_szuletesi_hely\" tabindex=\"5\" id=\"ff_16_jrsz_szuletesi_hely\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_1  has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Declaration by the person entitled:\">Declaration by the person entitled:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"jrsz_nyilatkozata_70d28580ac39e5dc1aa17c8a881d1a25\"><input  type=\"checkbox\" name=\"jrsz_nyilatkozata[]\" data-name=\"jrsz_nyilatkozata\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"6\" value=\"Felel\u0151ss\u00e9gem tudat\u00e1ban nyilatkozom, hogy jogosult vagyok a p\u00e1ciens k\u00e9pviselet\u00e9ben elj\u00e1rni.\"  id='jrsz_nyilatkozata_70d28580ac39e5dc1aa17c8a881d1a25' aria-label='I hereby declare that I have the right to represent the patient.' aria-invalid='false' aria-required=\"true\"> <span>I hereby declare that I have the right to represent the patient.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_2\" ><h6>Patient identification, registration<\/h6><\/div><div data-type=\"name-element\" data-name=\"paciens_neve\" class=\"ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_paciens_neve_first_name_' >Patient's surname<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_neve[first_name]\" id=\"ff_16_paciens_neve_first_name_\" class=\"ff-el-form-control\" placeholder=\"Last name\" tabindex=\"7\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_paciens_neve_last_name_' >Patient's first name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_neve[last_name]\" id=\"ff_16_paciens_neve_last_name_\" class=\"ff-el-form-control\" placeholder=\"First name\" tabindex=\"8\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_paciens_szuletesi_ideje' aria-label=\"Patient&#039;s date of birth\">Patient's date of birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='P\u00e1ciens sz\u00fclet\u00e9si ideje Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='Y-m-d' type=\"text\" name=\"paciens_szuletesi_ideje\" id=\"ff_16_paciens_szuletesi_ideje\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date of birth\" data-name=\"paciens_szuletesi_ideje\" tabindex=\"9\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_paciens_eszuletesi_helye' aria-label=\"Patient&#039;s place of birth\">Patient's place of birth<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_eszuletesi_helye\" class=\"ff-el-form-control\" data-name=\"paciens_eszuletesi_helye\" tabindex=\"10\" id=\"ff_16_paciens_eszuletesi_helye\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_paciens_edesanyjanak_leanykori_neve' aria-label=\"Patient&#039;s mother&#039;s maiden name\">Patient's mother's maiden name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_edesanyjanak_leanykori_neve\" class=\"ff-el-form-control\" data-name=\"paciens_edesanyjanak_leanykori_neve\" tabindex=\"11\" id=\"ff_16_paciens_edesanyjanak_leanykori_neve\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='12'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='13'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_3\" ><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_4\" ><h6>Contact details<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_email' aria-label=\"E-mail address\">E-mail address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_16_email\" class=\"ff-el-form-control\" placeholder=\"E-mail address\" data-name=\"email\" tabindex=\"14\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_telefonszam' aria-label=\"Phone number\">Phone number<\/label><\/div><div class='ff-el-input--content'><input name=\"telefonszam\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Phone number\" data-name=\"telefonszam\" id=\"ff_16_telefonszam\" tabindex=\"15\" inputmode=\"tel\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='16'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='17'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_5\" ><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_6\" ><h6>Personal data relating to the patient's treatment<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Patient&#039;s sex at birth\">Patient's sex at birth<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szuletesi_nem_9de7b0f4b7ccb9d2c2bd62d2460a369a\"><input  type=\"radio\" name=\"szuletesi_nem\" data-name=\"szuletesi_nem\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"18\" value=\"F\u00e9rfi\"  id='szuletesi_nem_9de7b0f4b7ccb9d2c2bd62d2460a369a' aria-label='Male' aria-invalid='false' aria-required=\"true\"> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szuletesi_nem_81b137741a967344f4cd03e10b23d839\"><input  type=\"radio\" name=\"szuletesi_nem\" data-name=\"szuletesi_nem\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"N\u0151\"  id='szuletesi_nem_81b137741a967344f4cd03e10b23d839' aria-label='Female' aria-invalid='false' aria-required=\"true\"> <span>Female<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_paciens_leanykori_neve' aria-label=\"Patient&#039;s maiden name:\">Patient's maiden name:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_leanykori_neve\" class=\"ff-el-form-control\" data-name=\"paciens_leanykori_neve\" tabindex=\"19\" id=\"ff_16_paciens_leanykori_neve\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_taj_vagy_szaisz' aria-label=\"Social security number or, in its absence, e.g. passport\">Social security number or, in its absence, e.g. passport<\/label><div class=\"ff-el-tooltip\" data-content=\"TAJ sz\u00e1m hi\u00e1ny\u00e1ban b\u00e1rmilyen szem\u00e9lyazonos\u00edt\u00e1sra alkalmas okm\u00e1ny sz\u00e1ma megfelel\u0151.\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"taj_vagy_szaisz\" class=\"ff-el-form-control\" data-name=\"taj_vagy_szaisz\" tabindex=\"20\" id=\"ff_16_taj_vagy_szaisz\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div data-type='tabular-element' data-name='anamnezis' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='Please provide a patient history (anamnesis):' for=''>Please provide a patient history (anamnesis):<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>The condition persists<\/th><th>The condition does not exist<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Allergy to medicines<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Allergy to medicines - The condition persists\" name=\"anamnezis[Gy\u00f3gyszerallergia]\" type=\"radio\" value=\"true\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Allergy to medicines-The condition does not exist\" name=\"anamnezis[Gy\u00f3gyszerallergia]\" type=\"radio\" value=\"false\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Chronic or infectious disease<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Chronic or infectious disease-Condition persists\" name=\"anamnezis[Kr\u00f3nikus vagy fert\u0151z\u0151 betegs\u00e9g]\" type=\"radio\" value=\"true\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Chronic or infectious disease-The condition is not present\" name=\"anamnezis[Kr\u00f3nikus vagy fert\u0151z\u0151 betegs\u00e9g]\" type=\"radio\" value=\"false\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Prolonged use of medicines<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Prolonged use of medication - Condition persists\" name=\"anamnezis[Gy\u00f3gyszerek tart\u00f3s szed\u00e9se]\" type=\"radio\" value=\"true\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Prolonged use of medication - Condition does not exist\" name=\"anamnezis[Gy\u00f3gyszerek tart\u00f3s szed\u00e9se]\" type=\"radio\" value=\"false\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Pregnant<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Pregnant-The condition persists\" name=\"anamnezis[V\u00e1rand\u00f3s]\" type=\"radio\" value=\"true\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Pregnant-The condition does not exist\" name=\"anamnezis[V\u00e1rand\u00f3s]\" type=\"radio\" value=\"false\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Breastfeeding<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Breastfeeding-The condition persists\" name=\"anamnezis[Szoptat\u00e1s]\" type=\"radio\" value=\"true\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Breastfeeding-The condition does not exist\" name=\"anamnezis[Szoptat\u00e1s]\" type=\"radio\" value=\"false\" tabindex=\"21\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><\/tbody><\/table><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_gyogyszerallergia_reszletezese' aria-label=\"What medicine are you allergic to and what reaction have you experienced?\">What medicine are you allergic to and what reaction have you experienced?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"gyogyszerallergia_reszletezese\" id=\"ff_16_gyogyszerallergia_reszletezese\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"gyogyszerallergia_reszletezese\" tabindex=\"22\" ><\/textarea><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_kronikus_vagy_fertozo_betegseg_reszletezese' aria-label=\"What chronic or infectious disease is it?\">What chronic or infectious disease is it?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"kronikus_vagy_fertozo_betegseg_reszletezese\" id=\"ff_16_kronikus_vagy_fertozo_betegseg_reszletezese\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"kronikus_vagy_fertozo_betegseg_reszletezese\" tabindex=\"23\" ><\/textarea><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_gyogyszer_tartos_szedesenek_reszletezese' aria-label=\"What medicines do you take regularly?\">What medicines do you take regularly?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"gyogyszer_tartos_szedesenek_reszletezese\" id=\"ff_16_gyogyszer_tartos_szedesenek_reszletezese\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"gyogyszer_tartos_szedesenek_reszletezese\" tabindex=\"24\" ><\/textarea><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"lakcim\" ><div class='ff-el-input--label'><label aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_lakcim_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"lakcim[country]\" id=\"ff_16_lakcim_country_\" class=\"ff-el-form-control\" placeholder=\"K\u00e9rlek v\u00e1laszd ki az orsz\u00e1got\" data-key_name=\"country\" tabindex=\"25\" aria-invalid='false' aria-required=\"true\"><option value=''>Please choose your country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_lakcim_zip_' aria-label=\"Postal code\">Postal code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[zip]\" id=\"ff_16_lakcim_zip_\" class=\"ff-el-form-control\" placeholder=\"Postal code\" data-key_name=\"zip\" tabindex=\"26\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_lakcim_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[city]\" id=\"ff_16_lakcim_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\" tabindex=\"27\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_lakcim_address_line_1_' aria-label=\"Street, house number\">Street, house number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[address_line_1]\" id=\"ff_16_lakcim_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Street, house number\" data-key_name=\"address_line_1\" tabindex=\"28\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_16_lakcim_address_line_2_' aria-label=\"Floor, door\">Floor, door<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[address_line_2]\" id=\"ff_16_lakcim_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Floor, door\" data-key_name=\"address_line_2\" tabindex=\"29\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_3 d-none'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group d-none'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Allergy to medicines\">Allergy to medicines<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogyszerallergia_radio_06fffbd584d6bacf9b23c849a5d895d5\"><input  type=\"radio\" name=\"gyogyszerallergia_radio\" data-name=\"gyogyszerallergia_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"30\" value=\"yes\"  id='gyogyszerallergia_radio_06fffbd584d6bacf9b23c849a5d895d5' aria-label='Have' aria-invalid='false' aria-required=\"false\"> <span>Have<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogyszerallergia_radio_5b7d9cfadaa6f7dc9ae0e07720b64ef3\"><input  type=\"radio\" name=\"gyogyszerallergia_radio\" data-name=\"gyogyszerallergia_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"no\"  id='gyogyszerallergia_radio_5b7d9cfadaa6f7dc9ae0e07720b64ef3' aria-label='None' aria-invalid='false' aria-required=\"false\"> <span>None<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group d-none'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Chronic or infectious disease\">Chronic or infectious disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"kronikus_vagy_fertozo_betegseg_radio_e76c5e3df92139a21504902c8da939e3\"><input  type=\"radio\" name=\"kronikus_vagy_fertozo_betegseg_radio\" data-name=\"kronikus_vagy_fertozo_betegseg_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"31\" value=\"yes\"  id='kronikus_vagy_fertozo_betegseg_radio_e76c5e3df92139a21504902c8da939e3' aria-label='Have' aria-invalid='false' aria-required=\"false\"> <span>Have<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"kronikus_vagy_fertozo_betegseg_radio_80fbbfc39fad77f90c6bcf401ccc18b2\"><input  type=\"radio\" name=\"kronikus_vagy_fertozo_betegseg_radio\" data-name=\"kronikus_vagy_fertozo_betegseg_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"no\"  id='kronikus_vagy_fertozo_betegseg_radio_80fbbfc39fad77f90c6bcf401ccc18b2' aria-label='None' aria-invalid='false' aria-required=\"false\"> <span>None<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group d-none'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Regular medication\">Regular medication<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"rendszeres_gyogyszerszedes_radio_231e38bffcf68e5a77ae8efac6aac3ca\"><input  type=\"radio\" name=\"rendszeres_gyogyszerszedes_radio\" data-name=\"rendszeres_gyogyszerszedes_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"32\" value=\"yes\"  id='rendszeres_gyogyszerszedes_radio_231e38bffcf68e5a77ae8efac6aac3ca' aria-label='Have' aria-invalid='false' aria-required=\"false\"> <span>Have<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"rendszeres_gyogyszerszedes_radio_05fdf698969f166257c9d723fbc351d1\"><input  type=\"radio\" name=\"rendszeres_gyogyszerszedes_radio\" data-name=\"rendszeres_gyogyszerszedes_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"no\"  id='rendszeres_gyogyszerszedes_radio_05fdf698969f166257c9d723fbc351d1' aria-label='None' aria-invalid='false' aria-required=\"false\"> <span>None<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='33'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='34'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_7\" ><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_8\" ><h6>Billing<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"In whose name can we issue the invoice?\">In whose name can we issue the invoice?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_8dd7ab25c4d18ceddcdd5a3b760243ab\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"35\" value=\"Mag\u00e1nszem\u00e9ly\"  id='szamla_kinek_a_nevere_8dd7ab25c4d18ceddcdd5a3b760243ab' aria-label='Individual' aria-invalid='false' aria-required=\"true\"> <span>Individual<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_8423436e43c652b1b46fc9a81c53e52f\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"C\u00e9g\"  id='szamla_kinek_a_nevere_8423436e43c652b1b46fc9a81c53e52f' aria-label='Company' aria-invalid='false' aria-required=\"true\"> <span>Company<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_a99e6396adeb19c440a22cff24645e2f\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"Eg\u00e9szs\u00e9gp\u00e9nzt\u00e1r\"  id='szamla_kinek_a_nevere_a99e6396adeb19c440a22cff24645e2f' aria-label='Health fund' aria-invalid='false' aria-required=\"true\"> <span>Health fund<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_71836569d3c6ea2c78c07f2ebea1a42a\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"Biztos\u00edt\u00f3t\u00e1rsas\u00e1g\"  id='szamla_kinek_a_nevere_71836569d3c6ea2c78c07f2ebea1a42a' aria-label='Insurance company' aria-invalid='false' aria-required=\"true\"> <span>Insurance company<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_szamlazasi_nev' aria-label=\"Billing name\">Billing name<\/label><div class=\"ff-el-tooltip\" data-content=\"Mag\u00e1nszem\u00e9ly eset\u00e9n a mag\u00e9nszem\u00e9ly neve; C\u00e9g eset\u00e9n a c\u00e9g neve; Eg\u00e9szs\u00e9gp\u00e9nzt\u00e1r eset\u00e9n az eg\u00e9szs\u00e9g\u00e9nzt\u00e1r neve; Biztos\u00edt\u00e1s eset\u00e9n a biztos\u00edt\u00f3 neve\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_nev\" class=\"ff-el-form-control\" placeholder=\"Billing name\" data-name=\"szamlazasi_nev\" tabindex=\"36\" id=\"ff_16_szamlazasi_nev\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_adoszam_szamlazashoz' aria-label=\"Tax number (for company)\">Tax number (for company)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"adoszam_szamlazashoz\" class=\"ff-el-form-control\" placeholder=\"Tax number\" data-name=\"adoszam_szamlazashoz\" tabindex=\"37\" id=\"ff_16_adoszam_szamlazashoz\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_egeszsegpenztari_tagazonosito' aria-label=\"Health Insurance Member Identifier\">Health Insurance Member Identifier<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"egeszsegpenztari_tagazonosito\" class=\"ff-el-form-control\" placeholder=\"Health Insurance Member Identifier\" data-name=\"egeszsegpenztari_tagazonosito\" tabindex=\"38\" id=\"ff_16_egeszsegpenztari_tagazonosito\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_biztositotarsasag_altal_kapott_azonosito' aria-label=\"Identifier issued by the insurance company\">Identifier issued by the insurance company<\/label><div class=\"ff-el-tooltip\" data-content=\"pl. k\u00f6tv\u00e9nysz\u00e1m, k\u00e1rtyasz\u00e1m\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"biztositotarsasag_altal_kapott_azonosito\" class=\"ff-el-form-control\" placeholder=\"e.g. bond number, card number\" data-name=\"biztositotarsasag_altal_kapott_azonosito\" tabindex=\"39\" id=\"ff_16_biztositotarsasag_altal_kapott_azonosito\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group has-conditions infoBlock'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"lakcim_szamlazasi_cim_elter_egymastol_b35b0241ac2834eb04d8cd83bb9c8c51\"><input  type=\"checkbox\" name=\"lakcim_szamlazasi_cim_elter_egymastol[]\" data-name=\"lakcim_szamlazasi_cim_elter_egymastol\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"40\" value=\"K\u00e9rj\u00fck jel\u00f6lje be, ha a lakc\u00edme \u00e9s a sz\u00e1ml\u00e1z\u00e1si c\u00edme elt\u00e9r egym\u00e1st\u00f3l.\"  id='lakcim_szamlazasi_cim_elter_egymastol_b35b0241ac2834eb04d8cd83bb9c8c51' aria-label='Please tick if your address and billing address are different.' aria-invalid='false' aria-required=\"false\"> <span>Please tick if your address and billing address are different.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class=\"ff-name-address-wrapper fluent-address has-conditions\" data-type=\"address-element\" data-name=\"szamlazasi_cim\" ><div class='ff-el-input--label'><label aria-label=\"Billing address\">Billing address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_szamlazasi_cim_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"szamlazasi_cim[country]\" id=\"ff_16_szamlazasi_cim_country_\" class=\"ff-el-form-control\" placeholder=\"K\u00e9rlek v\u00e1laszd ki az orsz\u00e1got\" data-key_name=\"country\" tabindex=\"41\" aria-invalid='false' aria-required=\"true\"><option value=''>Please choose your country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_szamlazasi_cim_zip_' aria-label=\"Postal code\">Postal code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[zip]\" id=\"ff_16_szamlazasi_cim_zip_\" class=\"ff-el-form-control\" placeholder=\"Postal code\" data-key_name=\"zip\" tabindex=\"42\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_szamlazasi_cim_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[city]\" id=\"ff_16_szamlazasi_cim_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\" tabindex=\"43\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_szamlazasi_cim_address_line_1_' aria-label=\"Street, house number\">Street, house number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[address_line_1]\" id=\"ff_16_szamlazasi_cim_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Street, house number\" data-key_name=\"address_line_1\" tabindex=\"44\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_16_szamlazasi_cim_address_line_2_' aria-label=\"Floor, door\">Floor, door<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[address_line_2]\" id=\"ff_16_szamlazasi_cim_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Floor, door\" data-key_name=\"address_line_2\" tabindex=\"45\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='46'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='47'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_9\" ><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_10\" ><h6>How much time do you have available for treatment?<\/h6>\n<p>Important: if you only have a very short time available (for example, you are leaving the next day), a longer, multi-part treatment is not possible and we will have to opt for a shorter, more urgent treatment. The time available for treatment is key to choosing the right treatment. Please therefore answer thoroughly and accurately.<\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Please tick the appropriate box for the patient:\">Please tick the appropriate box for the patient:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_8e62a6e18aac08490f3caed57c7bac40\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"48\" value=\"Csak &lt;strong&gt;egy alkalommal&lt;\/strong&gt; tudok j\u00f6nni (pl. elutaz\u00e1s)\"  id='gyogykezelesre_fordithato_ido_8e62a6e18aac08490f3caed57c7bac40' aria-label='Only &lt;strong&gt;once&lt;\/strong&gt; I can come (e.g. for a trip)' aria-invalid='false' aria-required=\"true\"> <span>Only <strong>once<\/strong> I can come (e.g. for a trip)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_cf6dc897bbb2b9d4afec786d2bbab0f4\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;N\u00e9h\u00e1ny napig vagyok el\u00e9rhet\u0151&lt;\/strong&gt;, de t\u00f6bbsz\u00f6r is vissza tudok j\u00f6nni ez id\u0151 alatt\"  id='gyogykezelesre_fordithato_ido_cf6dc897bbb2b9d4afec786d2bbab0f4' aria-label='&lt;strong&gt;I am available for a few days&lt;\/strong&gt;, but I can come back several times during this time' aria-invalid='false' aria-required=\"true\"> <span><strong>I am available for a few days<\/strong>, but I can come back several times during this time<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_0bf3b9ed177253d1d6e193edb937b33e\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;Egy-k\u00e9t h\u00e9tig&lt;\/strong&gt; el\u00e9rhet\u0151 vagyok, \u00edgy t\u00f6bb kezel\u00e9sre is van lehet\u0151s\u00e9g\"  id='gyogykezelesre_fordithato_ido_0bf3b9ed177253d1d6e193edb937b33e' aria-label='&lt;strong&gt;For a week or two&lt;\/strong&gt; I am available, so there are several treatments available' aria-invalid='false' aria-required=\"true\"> <span><strong>For a week or two<\/strong> I am available, so there are several treatments available<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_82665ca477a6e15f2f488e0e06da2c73\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;Egy h\u00f3napig&lt;\/strong&gt; vagy tov\u00e1bb itt maradok, a sz\u00fcks\u00e9ges kezel\u00e9sekre van id\u0151m\"  id='gyogykezelesre_fordithato_ido_82665ca477a6e15f2f488e0e06da2c73' aria-label='&lt;strong&gt;For one month&lt;\/strong&gt; or stay longer, I have time for the necessary treatments' aria-invalid='false' aria-required=\"true\"> <span><strong>For one month<\/strong> or stay longer, I have time for the necessary treatments<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_4f546f99d52f11ff931ff6f545993f53\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;Hossz\u00fa t\u00e1von is el\u00e9rhet\u0151 vagyok&lt;\/strong&gt;, \u00edgy a legoptim\u00e1lisabb kezel\u00e9st v\u00e1laszthatjuk\"  id='gyogykezelesre_fordithato_ido_4f546f99d52f11ff931ff6f545993f53' aria-label='&lt;strong&gt;I am available for the long term&lt;\/strong&gt;, so we can choose the most optimal treatment' aria-invalid='false' aria-required=\"true\"> <span><strong>I am available for the long term<\/strong>, so we can choose the most optimal treatment<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='49'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='50'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_11\" ><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_12\" ><h6>Details of the person to contact in the event of an emergency<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_veszhelyzeti_ertesitendo_szemely_neve' aria-label=\"Name of person to be notified\">Name of person to be notified<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"veszhelyzeti_ertesitendo_szemely_neve\" class=\"ff-el-form-control\" placeholder=\"Name\" data-name=\"veszhelyzeti_ertesitendo_szemely_neve\" tabindex=\"51\" id=\"ff_16_veszhelyzeti_ertesitendo_szemely_neve\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_veszhelyzeti_ertesitendo_szemely_telefonszama' aria-label=\"Phone number of the person to be notified\">Phone number of the person to be notified<\/label><\/div><div class='ff-el-input--content'><input name=\"veszhelyzeti_ertesitendo_szemely_telefonszama\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Phone number\" data-name=\"veszhelyzeti_ertesitendo_szemely_telefonszama\" id=\"ff_16_veszhelyzeti_ertesitendo_szemely_telefonszama\" tabindex=\"52\" inputmode=\"tel\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Data processing declaration:\">Data processing declaration:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"nyilatkozat_adatkezelesrol_e9a8b075ed70900057408219a5e8835a\"><input  type=\"checkbox\" name=\"nyilatkozat_adatkezelesrol[]\" data-name=\"nyilatkozat_adatkezelesrol\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"53\" value=\"Az &lt;a class=&quot;nyilatkozat_adatkezelesrol&quot; href=&quot;\/adatkezelesi-tajekoztato\/&quot; target=&quot;_blank&quot;&gt;adatkezel\u00e9si t\u00e1j\u00e9koztat\u00f3&lt;\/a&gt; tartalm\u00e1t megismertem, k\u00fcl\u00f6n\u00f6sen az azonos\u00edt\u00e1sr\u00f3l, kapcsolatfelv\u00e9telr\u0151l, gy\u00f3gykezel\u00e9sr\u0151l, sz\u00e1ml\u00e1z\u00e1sr\u00f3l sz\u00f3l\u00f3 r\u00e9szeket.\"  id='nyilatkozat_adatkezelesrol_e9a8b075ed70900057408219a5e8835a' aria-label='From &lt;a class=&quot;nyilatkozat_adatkezelesrol&quot; href=&quot;\/en\/privacy-policy\/&quot; target=&quot;_blank&quot;&gt;data management information&lt;\/a&gt; especially the parts on identification, contact, treatment and billing.' aria-invalid='false' aria-required=\"true\"> <span>From <a class=\"nyilatkozat_adatkezelesrol\" href=\"\/en\/privacy-policy\/\" target=\"_blank\">data management information<\/a> especially the parts on identification, contact, treatment and billing.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-text-left centerBtn ff_submit_btn_wrapper ff_submit_btn_wrapper_custom'><button class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style wpf_has_custom_css\" type=\"submit\" name=\"custom_submit_button-16_13\" data-name=\"custom_submit_button-16_13\" tabindex=\"54\" >Send<\/button><style>form.fluent_form_16 .wpf_has_custom_css.ff-btn-submit { background-color:#1a7efb;border-color:#1a7efb;color:#ffffff;border-radius:6px;min-width:33%; }form.fluent_form_16 .wpf_has_custom_css.ff-btn-submit:hover { background-color:#ffffff;border-color:#1a7efb;color:#1a7efb;border-radius:6px;min-width:33%; } <\/style><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button tabindex='55'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form><div id='fluentform_16_errors' class='ff-errors-in-stack ff_form_instance_16_1 ff-form-loading_errors ff_form_instance_16_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_16_1 = {\"id\":\"16\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_16_1\",\"form_id_selector\":\"fluentform_16\",\"rules\":{\"kerjuk_jelolje_ki_a_paciens\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"jrsz_neve[first_name]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck t\\u00f6ltse ki a vezet\\u00e9kn\\u00e9vre vonatkoz\\u00f3 r\\u00e9szt.\",\"global_message\":\"This field is required\",\"global\":false}},\"jrsz_neve[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"jrsz_neve[last_name]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck t\\u00f6ltse ki a keresztn\\u00e9vre vonatkoz\\u00f3 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required\",\"global\":false}},\"paciens_edesanyjanak_leanykori_neve\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck t\\u00f6ltse ki az \\u00e9desanyja le\\u00e1nykori nev\\u00e9re vonatkoz\\u00f3 mez\\u0151t.\",\"global_message\":\"This field is required\",\"global\":false}},\"email\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck t\\u00f6ltse ki az e-mail c\\u00edmet.\",\"global_message\":\"This field is required\",\"global\":false},\"email\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck ellen\\u0151rizze le az e-mail c\\u00edm helyess\\u00e9g\\u00e9t.\",\"global_message\":\"This field must contain a valid email\",\"global\":false}},\"telefonszam\":{\"required\":{\"value\":true,\"global\":false,\"message\":\"K\\u00e9rj\\u00fck t\\u00f6ltse ki a telefonsz\\u00e1mra vonatkoz\\u00f3 mez\\u0151t.\",\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":false,\"global\":false,\"message\":\"K\\u00e9rj\\u00fck ellen\\u0151rizze le a telefonsz\\u00e1m helyess\\u00e9g\\u00e9t.\",\"global_message\":\"Phone number is not valid\"}},\"szuletesi_nem\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck nyilatkozzon a p\\u00e1ciens sz\\u00fclet\\u00e9si nem\\u00e9t illet\\u0151en.\",\"global_message\":\"This field is required\",\"global\":false}},\"paciens_leanykori_neve\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adja meg a p\\u00e1ciens le\\u00e1nykori nev\\u00e9t.\",\"global_message\":\"This field is required\",\"global\":false}},\"taj_vagy_szaisz\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck \\u00edrja be TAJ sz\\u00e1m\\u00e1t vagy eg\\u00e9b szem\\u00e9lyazonos\\u00edt\\u00e1sra alkalmas igazolv\\u00e1ny sz\\u00e1m\\u00e1t (pl. \\u00fatlev\\u00e9lsz\\u00e1m).\",\"global_message\":\"This field is required\",\"global\":false}},\"anamnezis[Gy\\u00f3gyszerallergia]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck nyilatkozzon a p\\u00e1ciens k\\u00f3rel\\u0151zm\\u00e9ny\\u00e9r\\u0151l.\",\"global_message\":\"This field is required\",\"global\":false,\"per_row\":true}},\"anamnezis[Kr\\u00f3nikus vagy fert\\u0151z\\u0151 betegs\\u00e9g]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck nyilatkozzon a p\\u00e1ciens k\\u00f3rel\\u0151zm\\u00e9ny\\u00e9r\\u0151l.\",\"global_message\":\"This field is required\",\"global\":false,\"per_row\":true}},\"anamnezis[Gy\\u00f3gyszerek tart\\u00f3s szed\\u00e9se]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck nyilatkozzon a p\\u00e1ciens k\\u00f3rel\\u0151zm\\u00e9ny\\u00e9r\\u0151l.\",\"global_message\":\"This field is required\",\"global\":false,\"per_row\":true}},\"anamnezis[V\\u00e1rand\\u00f3s]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck nyilatkozzon a p\\u00e1ciens k\\u00f3rel\\u0151zm\\u00e9ny\\u00e9r\\u0151l.\",\"global_message\":\"This field is required\",\"global\":false,\"per_row\":true}},\"anamnezis[Szoptat\\u00e1s]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck nyilatkozzon a p\\u00e1ciens k\\u00f3rel\\u0151zm\\u00e9ny\\u00e9r\\u0151l.\",\"global_message\":\"This field is required\",\"global\":false,\"per_row\":true}},\"gyogyszerallergia_reszletezese\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck r\\u00e9szletesen nyilatkozzon a k\\u00f3rel\\u0151zm\\u00e9nyt illet\\u0151en.\",\"global_message\":\"This field is required\",\"global\":false}},\"kronikus_vagy_fertozo_betegseg_reszletezese\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck r\\u00e9szletesen nyilatkozzon a k\\u00f3rel\\u0151zm\\u00e9nyt illet\\u0151en.\",\"global_message\":\"This field is required\",\"global\":false}},\"gyogyszer_tartos_szedesenek_reszletezese\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck r\\u00e9szletesen nyilatkozzon a k\\u00f3rel\\u0151zm\\u00e9nyt illet\\u0151en.\",\"global_message\":\"This field is required\",\"global\":false}},\"lakcim[address_line_1]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adja meg az utc\\u00e1t \\u00e9s a h\\u00e1zsz\\u00e1mot.\",\"global_message\":\"This field is required\",\"global\":false}},\"lakcim[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"lakcim[city]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck, adja meg a v\\u00e1ros nev\\u00e9t.\",\"global_message\":\"This field is required\",\"global\":false}},\"lakcim[state]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck v\\u00e1lassza ki a megy\\u00e9t.\",\"global_message\":\"This field is required\",\"global\":false}},\"lakcim[zip]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck, adja meg az ir\\u00e1ny\\u00edt\\u00f3sz\\u00e1mot.\",\"global_message\":\"This field is required\",\"global\":false}},\"lakcim[country]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck v\\u00e1lassza ki az orsz\\u00e1got.\",\"global_message\":\"This field is required\",\"global\":false}},\"gyogyszerallergia_radio\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"kronikus_vagy_fertozo_betegseg_radio\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"rendszeres_gyogyszerszedes_radio\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"szamla_kinek_a_nevere\":{\"required\":{\"value\":true,\"message\":\"Kinek a nev\\u00e9re \\u00e1ll\\u00edthatjuk ki a sz\\u00e1ml\\u00e1t?\",\"global_message\":\"This field is required\",\"global\":false}},\"szamlazasi_nev\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adja meg a sz\\u00e1ml\\u00e1z\\u00e1si nevet.\",\"global_message\":\"This field is required\",\"global\":false}},\"adoszam_szamlazashoz\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adja meg a c\\u00e9g ad\\u00f3sz\\u00e1m\\u00e1t.\",\"global_message\":\"This field is required\",\"global\":false}},\"egeszsegpenztari_tagazonosito\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adja meg az eg\\u00e9szs\\u00e9gp\\u00e9nzt\\u00e1ri tagazonos\\u00edt\\u00f3j\\u00e1t.\",\"global_message\":\"This field is required\",\"global\":false}},\"biztositotarsasag_altal_kapott_azonosito\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adja meg a biztos\\u00edt\\u00f3t\\u00e1rsas\\u00e1g \\u00e1ltal kapott azonos\\u00edt\\u00f3j\\u00e1t.\",\"global_message\":\"This field is required\",\"global\":false}},\"lakcim_szamlazasi_cim_elter_egymastol\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"szamlazasi_cim[address_line_1]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adja meg az utc\\u00e1t \\u00e9s a h\\u00e1zsz\\u00e1mot.\",\"global_message\":\"This field is required\",\"global\":false}},\"szamlazasi_cim[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"szamlazasi_cim[city]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck, adja meg a v\\u00e1ros nev\\u00e9t.\",\"global_message\":\"This field is required\",\"global\":false}},\"szamlazasi_cim[state]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck v\\u00e1lassza ki a megy\\u00e9t.\",\"global_message\":\"This field is required\",\"global\":false}},\"szamlazasi_cim[zip]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck, adja meg az ir\\u00e1ny\\u00edt\\u00f3sz\\u00e1mot.\",\"global_message\":\"This field is required\",\"global\":false}},\"szamlazasi_cim[country]\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck v\\u00e1lassza ki az orsz\\u00e1got.\",\"global_message\":\"This field is required\",\"global\":false}},\"gyogykezelesre_fordithato_ido\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck v\\u00e1lasszon az opci\\u00f3k k\\u00f6z\\u00fcl.\",\"global_message\":\"This field is required\",\"global\":false}},\"veszhelyzeti_ertesitendo_szemely_neve\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck adjon meg egy olyan szem\\u00e9lyt, akit egy esetleges komplik\\u00e1ci\\u00f3 fell\\u00e9p\\u00e9sekor \\u00e9rtes\\u00edthet\\u00fcnk.\",\"global_message\":\"This field is required\",\"global\":false}},\"veszhelyzeti_ertesitendo_szemely_telefonszama\":{\"required\":{\"value\":true,\"global\":false,\"message\":\"K\\u00e9rj\\u00fck adja meg egy olyan szem\\u00e9ly telefonos el\\u00e9rhet\\u0151s\\u00e9g\\u00e9t, akit egy esetleges komplik\\u00e1ci\\u00f3 fell\\u00e9p\\u00e9sekor \\u00e9rtes\\u00edthet\\u00fcnk.\",\"global_message\":\"This field is required\"},\"valid_phone_number\":{\"value\":false,\"global\":false,\"message\":\"K\\u00e9rj\\u00fck ellen\\u0151rizze le a telefonsz\\u00e1m helyess\\u00e9g\\u00e9t.\",\"global_message\":\"Phone number is not valid\"}},\"nyilatkozat_adatkezelesrol\":{\"required\":{\"value\":true,\"message\":\"K\\u00e9rj\\u00fck olvassa el az adatkezel\\u00e9si t\\u00e1j\\u00e9koztat\\u00f3nkat, majd nyilatkozzon ennek megt\\u00f6rt\\u00e9ntj\\u00e9r\\u0151l.\",\"global_message\":\"This field is required\",\"global\":false}}},\"debounce_time\":300,\"conditionals\":{\"custom_html-16_1\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}]},\"jrsz_neve\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}]},\"ff_cn_id_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}]},\"jrsz_szuletesi_ideje\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}],\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}]}},\"jrsz_szuletesi_hely\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}],\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}]}},\"ff_cn_id_3\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}]},\"jrsz_nyilatkozata\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}],\"container_condition\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kerjuk_jelolje_ki_a_paciens\",\"value\":\"M\\u00e1s nev\\u00e9ben t\\u00f6lt\\u00f6m ki (pl. gyermek, hozz\\u00e1tartoz\\u00f3)\",\"operator\":\"=\"}]}},\"paciens_leanykori_neve\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"szuletesi_nem\",\"value\":\"N\\u0151\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"gyogyszerallergia_reszletezese\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"gyogyszerallergia_radio\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"kronikus_vagy_fertozo_betegseg_reszletezese\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"kronikus_vagy_fertozo_betegseg_radio\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"gyogyszer_tartos_szedesenek_reszletezese\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"rendszeres_gyogyszerszedes_radio\",\"value\":\"yes\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"adoszam_szamlazashoz\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"szamla_kinek_a_nevere\",\"value\":\"C\\u00e9g\",\"operator\":\"=\"}]},\"egeszsegpenztari_tagazonosito\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"szamla_kinek_a_nevere\",\"value\":\"Eg\\u00e9szs\\u00e9gp\\u00e9nzt\\u00e1r\",\"operator\":\"=\"}]},\"biztositotarsasag_altal_kapott_azonosito\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"szamla_kinek_a_nevere\",\"value\":\"Biztos\\u00edt\\u00f3t\\u00e1rsas\\u00e1g\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"lakcim_szamlazasi_cim_elter_egymastol\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"szamla_kinek_a_nevere\",\"value\":\"Mag\\u00e1nszem\\u00e9ly\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"\",\"value\":\"\",\"operator\":\"\"}],\"title\":\"\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]},\"szamlazasi_cim\":{\"type\":\"group\",\"status\":true,\"conditions\":[{\"field\":\"lakcim_szamlazasi_cim_megegyezik\",\"value\":\"K\\u00e9rj\\u00fck jel\\u00f6lje be, ha a lakc\\u00edme \\u00e9s a sz\\u00e1ml\\u00e1z\\u00e1si c\\u00edme megegyezik.\",\"operator\":\"!=\"},{\"field\":\"szamla_kinek_a_nevere\",\"value\":\"Mag\\u00e1nszem\\u00e9ly\",\"operator\":\"=\"}],\"condition_groups\":[{\"rules\":[{\"field\":\"szamla_kinek_a_nevere\",\"value\":\"Mag\\u00e1nszem\\u00e9ly\",\"operator\":\"=\"},{\"field\":\"lakcim_szamlazasi_cim_elter_egymastol\",\"value\":\"K\\u00e9rj\\u00fck jel\\u00f6lje be, ha a lakc\\u00edme \\u00e9s a sz\\u00e1ml\\u00e1z\\u00e1si c\\u00edme elt\\u00e9r egym\\u00e1st\\u00f3l.\",\"operator\":\"=\"}],\"title\":\"Mag\\u00e1nszem\\u00e9ly\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true},{\"rules\":[{\"field\":\"szamla_kinek_a_nevere\",\"value\":\"C\\u00e9g\",\"operator\":\"=\"}],\"title\":\"C\\u00e9g\",\"isEditingTitle\":false,\"isPreviewOpen\":false,\"isGroupOpen\":true}]}}};\n                    <\/script>\n        \n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>","protected":false},"excerpt":{"rendered":"<p>Registration<div class='fluentform ff-default fluentform_wrapper_16 ffs_custom_wrap'><form data-form_id=\"16\" id=\"fluentform_16\" class=\"frm-fluent-form fluent_form_16 ff-el-form-top ff_form_instance_16_2 ff-form-loading ff-form-has-steps ffs_custom\" data-form_instance=\"ff_form_instance_16_2\" method=\"POST\" action=\"\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Patient registration (#16)<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_16_item_sf\" aria-label=\"Subscribe\">\n                    Subscribe                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_16__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_16_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='691' \/><input type=\"hidden\" id=\"_fluentform_16_fluentformnonce\" name=\"_fluentform_16_fluentformnonce\" value=\"18ca3f6271\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/jogszeruonlinejelenlet_jijililjlililjliljliljlijliljlijilllijilljijliljilljllljliljlijlljlijllilljlllijijlljilljlijiljijlijlilililjlillljliljliljlijljijlliljlijijllijililjliljililjliljlijiljiljli\/wp\/v2\/pages\/79639\" \/><div class='ff-step-container' data-name=\"step_start-16_14\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div class='ff-step-header'><ul class='ff-step-titles'><li class='ff_active'><span>Identification<\/span><\/li><li><span>Contact<\/span><\/li><li><span>Treatment<\/span><\/li><li><span>Billing<\/span><\/li><li><span>Time to treatment<\/span><\/li><li><span>Related<\/span><\/li><\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-16_14\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group center infoBlock ff_list_inline'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Please indicate whether you are the patient or filling in the form on behalf of someone else.\">Please indicate whether you are the patient or filling in the form on behalf of someone else.<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for=\"kerjuk_jelolje_ki_a_paciens_30b538e70d94670193ffd186dae1066b\"><input  type=\"radio\" name=\"kerjuk_jelolje_ki_a_paciens\" data-name=\"kerjuk_jelolje_ki_a_paciens\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" tabindex=\"56\" value=\"\u00c9n vagyok a p\u00e1ciens\"  id='kerjuk_jelolje_ki_a_paciens_30b538e70d94670193ffd186dae1066b' aria-label='I am the patient' aria-invalid='false' aria-required=\"false\"> <span>I am the patient<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"kerjuk_jelolje_ki_a_paciens_5feeaafb8a6693a7b9c43d8fdf688b6d\"><input  type=\"radio\" name=\"kerjuk_jelolje_ki_a_paciens\" data-name=\"kerjuk_jelolje_ki_a_paciens\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"M\u00e1s nev\u00e9ben t\u00f6lt\u00f6m ki (pl. gyermek, hozz\u00e1tartoz\u00f3)\"  id='kerjuk_jelolje_ki_a_paciens_5feeaafb8a6693a7b9c43d8fdf688b6d' aria-label='I am filling in on behalf of someone else (e.g. child, relative)' aria-invalid='false' aria-required=\"false\"> <span>I am filling in on behalf of someone else (e.g. child, relative)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-16_1\" ><h6>Identification and declaration of the person entitled<\/h6><\/div><div data-type=\"name-element\" data-name=\"jrsz_neve\" class=\"has-conditions  ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_jrsz_neve_first_name_' >Last name of the person entitled<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"jrsz_neve[first_name]\" id=\"ff_16_2_jrsz_neve_first_name_\" class=\"ff-el-form-control\" placeholder=\"Last name\" tabindex=\"57\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_jrsz_neve_last_name_' >First name of the person entitled<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"jrsz_neve[last_name]\" id=\"ff_16_2_jrsz_neve_last_name_\" class=\"ff-el-form-control\" placeholder=\"First name\" tabindex=\"58\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_jrsz_szuletesi_ideje' aria-label=\"Eligible person&#039;s date of birth\">Eligible person's date of birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Jogosults\u00e1ggal rendelkez\u0151 szem\u00e9ly sz\u00fclet\u00e9si ideje Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='Y-m-d' type=\"text\" name=\"jrsz_szuletesi_ideje\" id=\"ff_16_2_jrsz_szuletesi_ideje\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date of birth\" data-name=\"jrsz_szuletesi_ideje\" tabindex=\"59\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_jrsz_szuletesi_hely' aria-label=\"Place of birth of the beneficiary\">Place of birth of the beneficiary<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"jrsz_szuletesi_hely\" class=\"ff-el-form-control\" data-name=\"jrsz_szuletesi_hely\" tabindex=\"60\" id=\"ff_16_2_jrsz_szuletesi_hely\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_1  has-conditions'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Declaration by the person entitled:\">Declaration by the person entitled:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"jrsz_nyilatkozata_002a2775a5226987b72b06a907b48ced\"><input  type=\"checkbox\" name=\"jrsz_nyilatkozata[]\" data-name=\"jrsz_nyilatkozata\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"61\" value=\"Felel\u0151ss\u00e9gem tudat\u00e1ban nyilatkozom, hogy jogosult vagyok a p\u00e1ciens k\u00e9pviselet\u00e9ben elj\u00e1rni.\"  id='jrsz_nyilatkozata_002a2775a5226987b72b06a907b48ced' aria-label='I hereby declare that I have the right to represent the patient.' aria-invalid='false' aria-required=\"true\"> <span>I hereby declare that I have the right to represent the patient.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_2\" ><h6>Patient identification, registration<\/h6><\/div><div data-type=\"name-element\" data-name=\"paciens_neve\" class=\"ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_paciens_neve_first_name_' >Patient's surname<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_neve[first_name]\" id=\"ff_16_2_paciens_neve_first_name_\" class=\"ff-el-form-control\" placeholder=\"Last name\" tabindex=\"62\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_paciens_neve_last_name_' >Patient's first name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_neve[last_name]\" id=\"ff_16_2_paciens_neve_last_name_\" class=\"ff-el-form-control\" placeholder=\"First name\" tabindex=\"63\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_paciens_szuletesi_ideje' aria-label=\"Patient&#039;s date of birth\">Patient's date of birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='P\u00e1ciens sz\u00fclet\u00e9si ideje Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='Y-m-d' type=\"text\" name=\"paciens_szuletesi_ideje\" id=\"ff_16_2_paciens_szuletesi_ideje\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"Date of birth\" data-name=\"paciens_szuletesi_ideje\" tabindex=\"64\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_paciens_eszuletesi_helye' aria-label=\"Patient&#039;s place of birth\">Patient's place of birth<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_eszuletesi_helye\" class=\"ff-el-form-control\" data-name=\"paciens_eszuletesi_helye\" tabindex=\"65\" id=\"ff_16_2_paciens_eszuletesi_helye\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_paciens_edesanyjanak_leanykori_neve' aria-label=\"Patient&#039;s mother&#039;s maiden name\">Patient's mother's maiden name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_edesanyjanak_leanykori_neve\" class=\"ff-el-form-control\" data-name=\"paciens_edesanyjanak_leanykori_neve\" tabindex=\"66\" id=\"ff_16_2_paciens_edesanyjanak_leanykori_neve\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='67'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='68'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_3\" ><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_4\" ><h6>Contact details<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_email' aria-label=\"E-mail address\">E-mail address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_16_2_email\" class=\"ff-el-form-control\" placeholder=\"E-mail address\" data-name=\"email\" tabindex=\"69\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_telefonszam' aria-label=\"Phone number\">Phone number<\/label><\/div><div class='ff-el-input--content'><input name=\"telefonszam\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Phone number\" data-name=\"telefonszam\" id=\"ff_16_2_telefonszam\" tabindex=\"70\" inputmode=\"tel\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='71'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='72'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_5\" ><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_6\" ><h6>Personal data relating to the patient's treatment<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_10\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Patient&#039;s sex at birth\">Patient's sex at birth<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szuletesi_nem_6c1f086ded00db883ea8c9f2ee43c9b7\"><input  type=\"radio\" name=\"szuletesi_nem\" data-name=\"szuletesi_nem\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"73\" value=\"F\u00e9rfi\"  id='szuletesi_nem_6c1f086ded00db883ea8c9f2ee43c9b7' aria-label='Male' aria-invalid='false' aria-required=\"true\"> <span>Male<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szuletesi_nem_250827561582ea9c19dd0484e393551b\"><input  type=\"radio\" name=\"szuletesi_nem\" data-name=\"szuletesi_nem\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"N\u0151\"  id='szuletesi_nem_250827561582ea9c19dd0484e393551b' aria-label='Female' aria-invalid='false' aria-required=\"true\"> <span>Female<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_paciens_leanykori_neve' aria-label=\"Patient&#039;s maiden name:\">Patient's maiden name:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"paciens_leanykori_neve\" class=\"ff-el-form-control\" data-name=\"paciens_leanykori_neve\" tabindex=\"74\" id=\"ff_16_2_paciens_leanykori_neve\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_taj_vagy_szaisz' aria-label=\"Social security number or, in its absence, e.g. passport\">Social security number or, in its absence, e.g. passport<\/label><div class=\"ff-el-tooltip\" data-content=\"TAJ sz\u00e1m hi\u00e1ny\u00e1ban b\u00e1rmilyen szem\u00e9lyazonos\u00edt\u00e1sra alkalmas okm\u00e1ny sz\u00e1ma megfelel\u0151.\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"taj_vagy_szaisz\" class=\"ff-el-form-control\" data-name=\"taj_vagy_szaisz\" tabindex=\"75\" id=\"ff_16_2_taj_vagy_szaisz\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_11\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div data-type='tabular-element' data-name='anamnezis' class='ff-el-group'><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='Please provide a patient history (anamnesis):' for=''>Please provide a patient history (anamnesis):<\/label><\/div><div class='ff-el-input--content'><table class='ff-table ff-checkable-grids ff_flexible_table' role='table'><thead><tr><th><\/th><th>The condition persists<\/th><th>The condition does not exist<\/th><\/tr><\/thead><tbody><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Allergy to medicines<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Allergy to medicines - The condition persists\" name=\"anamnezis[Gy\u00f3gyszerallergia]\" type=\"radio\" value=\"true\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Allergy to medicines-The condition does not exist\" name=\"anamnezis[Gy\u00f3gyszerallergia]\" type=\"radio\" value=\"false\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Chronic or infectious disease<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Chronic or infectious disease-Condition persists\" name=\"anamnezis[Kr\u00f3nikus vagy fert\u0151z\u0151 betegs\u00e9g]\" type=\"radio\" value=\"true\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Chronic or infectious disease-The condition is not present\" name=\"anamnezis[Kr\u00f3nikus vagy fert\u0151z\u0151 betegs\u00e9g]\" type=\"radio\" value=\"false\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Prolonged use of medicines<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Prolonged use of medication - Condition persists\" name=\"anamnezis[Gy\u00f3gyszerek tart\u00f3s szed\u00e9se]\" type=\"radio\" value=\"true\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Prolonged use of medication - Condition does not exist\" name=\"anamnezis[Gy\u00f3gyszerek tart\u00f3s szed\u00e9se]\" type=\"radio\" value=\"false\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Pregnant<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Pregnant-The condition persists\" name=\"anamnezis[V\u00e1rand\u00f3s]\" type=\"radio\" value=\"true\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Pregnant-The condition does not exist\" name=\"anamnezis[V\u00e1rand\u00f3s]\" type=\"radio\" value=\"false\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><tr role=\"row\"\"><td class='ff_grid_header' role='cell'>Breastfeeding<\/td><td data-label='Az \u00e1llapot fenn\u00e1ll'><input aria-label=\"Breastfeeding-The condition persists\" name=\"anamnezis[Szoptat\u00e1s]\" type=\"radio\" value=\"true\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><td data-label='Az \u00e1llapot nem \u00e1ll fenn'><input aria-label=\"Breastfeeding-The condition does not exist\" name=\"anamnezis[Szoptat\u00e1s]\" type=\"radio\" value=\"false\" tabindex=\"76\"   aria-invalid='false' aria-required=\"true\"><\/td><\/tr><\/tbody><\/table><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_gyogyszerallergia_reszletezese' aria-label=\"What medicine are you allergic to and what reaction have you experienced?\">What medicine are you allergic to and what reaction have you experienced?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"gyogyszerallergia_reszletezese\" id=\"ff_16_2_gyogyszerallergia_reszletezese\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"gyogyszerallergia_reszletezese\" tabindex=\"77\" ><\/textarea><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_kronikus_vagy_fertozo_betegseg_reszletezese' aria-label=\"What chronic or infectious disease is it?\">What chronic or infectious disease is it?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"kronikus_vagy_fertozo_betegseg_reszletezese\" id=\"ff_16_2_kronikus_vagy_fertozo_betegseg_reszletezese\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"kronikus_vagy_fertozo_betegseg_reszletezese\" tabindex=\"78\" ><\/textarea><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_gyogyszer_tartos_szedesenek_reszletezese' aria-label=\"What medicines do you take regularly?\">What medicines do you take regularly?<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"gyogyszer_tartos_szedesenek_reszletezese\" id=\"ff_16_2_gyogyszer_tartos_szedesenek_reszletezese\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"gyogyszer_tartos_szedesenek_reszletezese\" tabindex=\"79\" ><\/textarea><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"lakcim\" ><div class='ff-el-input--label'><label aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_lakcim_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"lakcim[country]\" id=\"ff_16_2_lakcim_country_\" class=\"ff-el-form-control\" placeholder=\"K\u00e9rlek v\u00e1laszd ki az orsz\u00e1got\" data-key_name=\"country\" tabindex=\"80\" aria-invalid='false' aria-required=\"true\"><option value=''>Please choose your country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_lakcim_zip_' aria-label=\"Postal code\">Postal code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[zip]\" id=\"ff_16_2_lakcim_zip_\" class=\"ff-el-form-control\" placeholder=\"Postal code\" data-key_name=\"zip\" tabindex=\"81\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_lakcim_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[city]\" id=\"ff_16_2_lakcim_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\" tabindex=\"82\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_lakcim_address_line_1_' aria-label=\"Street, house number\">Street, house number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[address_line_1]\" id=\"ff_16_2_lakcim_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Street, house number\" data-key_name=\"address_line_1\" tabindex=\"83\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_16_2_lakcim_address_line_2_' aria-label=\"Floor, door\">Floor, door<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"lakcim[address_line_2]\" id=\"ff_16_2_lakcim_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Floor, door\" data-key_name=\"address_line_2\" tabindex=\"84\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_12\"  class='ff-t-container ff-column-container ff_columns_total_3 d-none'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group d-none'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Allergy to medicines\">Allergy to medicines<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogyszerallergia_radio_666cd9cb7859262baf778b48ebb30596\"><input  type=\"radio\" name=\"gyogyszerallergia_radio\" data-name=\"gyogyszerallergia_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"85\" value=\"yes\"  id='gyogyszerallergia_radio_666cd9cb7859262baf778b48ebb30596' aria-label='Have' aria-invalid='false' aria-required=\"false\"> <span>Have<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogyszerallergia_radio_fb995064db9dea84136203a0930746dd\"><input  type=\"radio\" name=\"gyogyszerallergia_radio\" data-name=\"gyogyszerallergia_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"no\"  id='gyogyszerallergia_radio_fb995064db9dea84136203a0930746dd' aria-label='None' aria-invalid='false' aria-required=\"false\"> <span>None<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group d-none'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Chronic or infectious disease\">Chronic or infectious disease<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"kronikus_vagy_fertozo_betegseg_radio_dc0ffc7e4a5f89d8e5e469b962066533\"><input  type=\"radio\" name=\"kronikus_vagy_fertozo_betegseg_radio\" data-name=\"kronikus_vagy_fertozo_betegseg_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"86\" value=\"yes\"  id='kronikus_vagy_fertozo_betegseg_radio_dc0ffc7e4a5f89d8e5e469b962066533' aria-label='Have' aria-invalid='false' aria-required=\"false\"> <span>Have<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"kronikus_vagy_fertozo_betegseg_radio_5c818ab5da9280c9367869f1a68ceea5\"><input  type=\"radio\" name=\"kronikus_vagy_fertozo_betegseg_radio\" data-name=\"kronikus_vagy_fertozo_betegseg_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"no\"  id='kronikus_vagy_fertozo_betegseg_radio_5c818ab5da9280c9367869f1a68ceea5' aria-label='None' aria-invalid='false' aria-required=\"false\"> <span>None<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group d-none'><div class=\"ff-el-input--label asterisk-right\"><label  aria-label=\"Regular medication\">Regular medication<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"rendszeres_gyogyszerszedes_radio_154e8dc03d22079c46d23942165b27e0\"><input  type=\"radio\" name=\"rendszeres_gyogyszerszedes_radio\" data-name=\"rendszeres_gyogyszerszedes_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"87\" value=\"yes\"  id='rendszeres_gyogyszerszedes_radio_154e8dc03d22079c46d23942165b27e0' aria-label='Have' aria-invalid='false' aria-required=\"false\"> <span>Have<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"rendszeres_gyogyszerszedes_radio_4caa45f1aa7a181c7807467fbe54fe49\"><input  type=\"radio\" name=\"rendszeres_gyogyszerszedes_radio\" data-name=\"rendszeres_gyogyszerszedes_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"no\"  id='rendszeres_gyogyszerszedes_radio_4caa45f1aa7a181c7807467fbe54fe49' aria-label='None' aria-invalid='false' aria-required=\"false\"> <span>None<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='88'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='89'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_7\" ><div data-name=\"ff_cn_id_13\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_8\" ><h6>Billing<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_14\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"In whose name can we issue the invoice?\">In whose name can we issue the invoice?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_4d339b0621d504f773bf0986cad1b5cf\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"90\" value=\"Mag\u00e1nszem\u00e9ly\"  id='szamla_kinek_a_nevere_4d339b0621d504f773bf0986cad1b5cf' aria-label='Individual' aria-invalid='false' aria-required=\"true\"> <span>Individual<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_a6f17a09daa7c9994ce041e04d5ef55b\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"C\u00e9g\"  id='szamla_kinek_a_nevere_a6f17a09daa7c9994ce041e04d5ef55b' aria-label='Company' aria-invalid='false' aria-required=\"true\"> <span>Company<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_6948a8d1e11031778034f4053abf2005\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"Eg\u00e9szs\u00e9gp\u00e9nzt\u00e1r\"  id='szamla_kinek_a_nevere_6948a8d1e11031778034f4053abf2005' aria-label='Health fund' aria-invalid='false' aria-required=\"true\"> <span>Health fund<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"szamla_kinek_a_nevere_b47dcd3b08faac0c3d5945a82f3be0ad\"><input  type=\"radio\" name=\"szamla_kinek_a_nevere\" data-name=\"szamla_kinek_a_nevere\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"Biztos\u00edt\u00f3t\u00e1rsas\u00e1g\"  id='szamla_kinek_a_nevere_b47dcd3b08faac0c3d5945a82f3be0ad' aria-label='Insurance company' aria-invalid='false' aria-required=\"true\"> <span>Insurance company<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_15\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_szamlazasi_nev' aria-label=\"Billing name\">Billing name<\/label><div class=\"ff-el-tooltip\" data-content=\"Mag\u00e1nszem\u00e9ly eset\u00e9n a mag\u00e9nszem\u00e9ly neve; C\u00e9g eset\u00e9n a c\u00e9g neve; Eg\u00e9szs\u00e9gp\u00e9nzt\u00e1r eset\u00e9n az eg\u00e9szs\u00e9g\u00e9nzt\u00e1r neve; Biztos\u00edt\u00e1s eset\u00e9n a biztos\u00edt\u00f3 neve\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_nev\" class=\"ff-el-form-control\" placeholder=\"Billing name\" data-name=\"szamlazasi_nev\" tabindex=\"91\" id=\"ff_16_2_szamlazasi_nev\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_adoszam_szamlazashoz' aria-label=\"Tax number (for company)\">Tax number (for company)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"adoszam_szamlazashoz\" class=\"ff-el-form-control\" placeholder=\"Tax number\" data-name=\"adoszam_szamlazashoz\" tabindex=\"92\" id=\"ff_16_2_adoszam_szamlazashoz\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_egeszsegpenztari_tagazonosito' aria-label=\"Health Insurance Member Identifier\">Health Insurance Member Identifier<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"egeszsegpenztari_tagazonosito\" class=\"ff-el-form-control\" placeholder=\"Health Insurance Member Identifier\" data-name=\"egeszsegpenztari_tagazonosito\" tabindex=\"93\" id=\"ff_16_2_egeszsegpenztari_tagazonosito\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_biztositotarsasag_altal_kapott_azonosito' aria-label=\"Identifier issued by the insurance company\">Identifier issued by the insurance company<\/label><div class=\"ff-el-tooltip\" data-content=\"pl. k\u00f6tv\u00e9nysz\u00e1m, k\u00e1rtyasz\u00e1m\"><svg width=\"16\" height=\"16\" viewbox=\"0 0 25 25\"><path d=\"m329 393l0-46c0-2-1-4-2-6-2-2-4-3-7-3l-27 0 0-146c0-3-1-5-3-7-2-1-4-2-7-2l-91 0c-3 0-5 1-7 2-1 2-2 4-2 7l0 46c0 2 1 5 2 6 2 2 4 3 7 3l27 0 0 91-27 0c-3 0-5 1-7 3-1 2-2 4-2 6l0 46c0 3 1 5 2 7 2 1 4 2 7 2l128 0c3 0 5-1 7-2 1-2 2-4 2-7z m-36-256l0-46c0-2-1-4-3-6-2-2-4-3-7-3l-54 0c-3 0-5 1-7 3-2 2-3 4-3 6l0 46c0 3 1 5 3 7 2 1 4 2 7 2l54 0c3 0 5-1 7-2 2-2 3-4 3-7z m182 119c0 40-9 77-29 110-20 34-46 60-80 80-33 20-70 29-110 29-40 0-77-9-110-29-34-20-60-46-80-80-20-33-29-70-29-110 0-40 9-77 29-110 20-34 46-60 80-80 33-20 70-29 110-29 40 0 77 9 110 29 34 20 60 46 80 80 20 33 29 70 29 110z\" transform=\"scale(0.046875 0.046875)\"><\/path><\/svg><\/div><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"biztositotarsasag_altal_kapott_azonosito\" class=\"ff-el-form-control\" placeholder=\"e.g. bond number, card number\" data-name=\"biztositotarsasag_altal_kapott_azonosito\" tabindex=\"94\" id=\"ff_16_2_biztositotarsasag_altal_kapott_azonosito\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_16\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group has-conditions infoBlock'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"lakcim_szamlazasi_cim_elter_egymastol_61fc254a8990cc4a37bb83f7407946b0\"><input  type=\"checkbox\" name=\"lakcim_szamlazasi_cim_elter_egymastol[]\" data-name=\"lakcim_szamlazasi_cim_elter_egymastol\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"95\" value=\"K\u00e9rj\u00fck jel\u00f6lje be, ha a lakc\u00edme \u00e9s a sz\u00e1ml\u00e1z\u00e1si c\u00edme elt\u00e9r egym\u00e1st\u00f3l.\"  id='lakcim_szamlazasi_cim_elter_egymastol_61fc254a8990cc4a37bb83f7407946b0' aria-label='Please tick if your address and billing address are different.' aria-invalid='false' aria-required=\"false\"> <span>Please tick if your address and billing address are different.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_17\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class=\"ff-name-address-wrapper fluent-address has-conditions\" data-type=\"address-element\" data-name=\"szamlazasi_cim\" ><div class='ff-el-input--label'><label aria-label=\"Billing address\">Billing address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_szamlazasi_cim_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"szamlazasi_cim[country]\" id=\"ff_16_2_szamlazasi_cim_country_\" class=\"ff-el-form-control\" placeholder=\"K\u00e9rlek v\u00e1laszd ki az orsz\u00e1got\" data-key_name=\"country\" tabindex=\"96\" aria-invalid='false' aria-required=\"true\"><option value=''>Please choose your country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='CV' >Cape Verde<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura&ccedil;ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MK' >Macedonia<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RE' >Reunion<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth&eacute;lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >Turkey<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_szamlazasi_cim_zip_' aria-label=\"Postal code\">Postal code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[zip]\" id=\"ff_16_2_szamlazasi_cim_zip_\" class=\"ff-el-form-control\" placeholder=\"Postal code\" data-key_name=\"zip\" tabindex=\"97\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_szamlazasi_cim_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[city]\" id=\"ff_16_2_szamlazasi_cim_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\" tabindex=\"98\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_szamlazasi_cim_address_line_1_' aria-label=\"Street, house number\">Street, house number<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[address_line_1]\" id=\"ff_16_2_szamlazasi_cim_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Street, house number\" data-key_name=\"address_line_1\" tabindex=\"99\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_16_2_szamlazasi_cim_address_line_2_' aria-label=\"Floor, door\">Floor, door<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"szamlazasi_cim[address_line_2]\" id=\"ff_16_2_szamlazasi_cim_address_line_2_\" class=\"ff-el-form-control\" placeholder=\"Floor, door\" data-key_name=\"address_line_2\" tabindex=\"100\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='101'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='102'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_9\" ><div data-name=\"ff_cn_id_18\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_10\" ><h6>How much time do you have available for treatment?<\/h6>\n<p>Important: if you only have a very short time available (for example, you are leaving the next day), a longer, multi-part treatment is not possible and we will have to opt for a shorter, more urgent treatment. The time available for treatment is key to choosing the right treatment. Please therefore answer thoroughly and accurately.<\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Please tick the appropriate box for the patient:\">Please tick the appropriate box for the patient:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_814b25e9adb07eba244f4918fb0ad599\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"103\" value=\"Csak &lt;strong&gt;egy alkalommal&lt;\/strong&gt; tudok j\u00f6nni (pl. elutaz\u00e1s)\"  id='gyogykezelesre_fordithato_ido_814b25e9adb07eba244f4918fb0ad599' aria-label='Only &lt;strong&gt;once&lt;\/strong&gt; I can come (e.g. for a trip)' aria-invalid='false' aria-required=\"true\"> <span>Only <strong>once<\/strong> I can come (e.g. for a trip)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_324cb8bf768eebc993eb80cf76e0c7c7\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;N\u00e9h\u00e1ny napig vagyok el\u00e9rhet\u0151&lt;\/strong&gt;, de t\u00f6bbsz\u00f6r is vissza tudok j\u00f6nni ez id\u0151 alatt\"  id='gyogykezelesre_fordithato_ido_324cb8bf768eebc993eb80cf76e0c7c7' aria-label='&lt;strong&gt;I am available for a few days&lt;\/strong&gt;, but I can come back several times during this time' aria-invalid='false' aria-required=\"true\"> <span><strong>I am available for a few days<\/strong>, but I can come back several times during this time<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_27c18af51800231b473ec347bb7023e7\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;Egy-k\u00e9t h\u00e9tig&lt;\/strong&gt; el\u00e9rhet\u0151 vagyok, \u00edgy t\u00f6bb kezel\u00e9sre is van lehet\u0151s\u00e9g\"  id='gyogykezelesre_fordithato_ido_27c18af51800231b473ec347bb7023e7' aria-label='&lt;strong&gt;For a week or two&lt;\/strong&gt; I am available, so there are several treatments available' aria-invalid='false' aria-required=\"true\"> <span><strong>For a week or two<\/strong> I am available, so there are several treatments available<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_675ad1ceb91dc54581627db727647561\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;Egy h\u00f3napig&lt;\/strong&gt; vagy tov\u00e1bb itt maradok, a sz\u00fcks\u00e9ges kezel\u00e9sekre van id\u0151m\"  id='gyogykezelesre_fordithato_ido_675ad1ceb91dc54581627db727647561' aria-label='&lt;strong&gt;For one month&lt;\/strong&gt; or stay longer, I have time for the necessary treatments' aria-invalid='false' aria-required=\"true\"> <span><strong>For one month<\/strong> or stay longer, I have time for the necessary treatments<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"gyogykezelesre_fordithato_ido_2c4e55d14deb73e543a8384362160c93\"><input  type=\"radio\" name=\"gyogykezelesre_fordithato_ido\" data-name=\"gyogykezelesre_fordithato_ido\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"&lt;strong&gt;Hossz\u00fa t\u00e1von is el\u00e9rhet\u0151 vagyok&lt;\/strong&gt;, \u00edgy a legoptim\u00e1lisabb kezel\u00e9st v\u00e1laszthatjuk\"  id='gyogykezelesre_fordithato_ido_2c4e55d14deb73e543a8384362160c93' aria-label='&lt;strong&gt;I am available for the long term&lt;\/strong&gt;, so we can choose the most optimal treatment' aria-invalid='false' aria-required=\"true\"> <span><strong>I am available for the long term<\/strong>, so we can choose the most optimal treatment<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='step-nav ff_step_nav_last'><button tabindex='104'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button tabindex='105'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div class=\"fluentform-step\" data-name=\"form_step-16_11\" ><div data-name=\"ff_cn_id_19\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-16_12\" ><h6>Details of the person to contact in the event of an emergency<\/h6><\/div><\/div><\/div><div data-name=\"ff_cn_id_20\"  class='ff-t-container ff-column-container ff_columns_total_2'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_veszhelyzeti_ertesitendo_szemely_neve' aria-label=\"Name of person to be notified\">Name of person to be notified<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"veszhelyzeti_ertesitendo_szemely_neve\" class=\"ff-el-form-control\" placeholder=\"Name\" data-name=\"veszhelyzeti_ertesitendo_szemely_neve\" tabindex=\"106\" id=\"ff_16_2_veszhelyzeti_ertesitendo_szemely_neve\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_16_2_veszhelyzeti_ertesitendo_szemely_telefonszama' aria-label=\"Phone number of the person to be notified\">Phone number of the person to be notified<\/label><\/div><div class='ff-el-input--content'><input name=\"veszhelyzeti_ertesitendo_szemely_telefonszama\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Phone number\" data-name=\"veszhelyzeti_ertesitendo_szemely_telefonszama\" id=\"ff_16_2_veszhelyzeti_ertesitendo_szemely_telefonszama\" tabindex=\"107\" inputmode=\"tel\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_21\"  class='ff-t-container ff-column-container ff_columns_total_1'><div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Data processing declaration:\">Data processing declaration:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"nyilatkozat_adatkezelesrol_105b314323fb03600fe9aab81486f5ba\"><input  type=\"checkbox\" name=\"nyilatkozat_adatkezelesrol[]\" data-name=\"nyilatkozat_adatkezelesrol\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"108\" value=\"Az &lt;a class=&quot;nyilatkozat_adatkezelesrol&quot; href=&quot;\/adatkezelesi-tajekoztato\/&quot; target=&quot;_blank&quot;&gt;adatkezel\u00e9si t\u00e1j\u00e9koztat\u00f3&lt;\/a&gt; tartalm\u00e1t megismertem, k\u00fcl\u00f6n\u00f6sen az azonos\u00edt\u00e1sr\u00f3l, kapcsolatfelv\u00e9telr\u0151l, gy\u00f3gykezel\u00e9sr\u0151l, sz\u00e1ml\u00e1z\u00e1sr\u00f3l sz\u00f3l\u00f3 r\u00e9szeket.\"  id='nyilatkozat_adatkezelesrol_105b314323fb03600fe9aab81486f5ba' aria-label='From &lt;a class=&quot;nyilatkozat_adatkezelesrol&quot; href=&quot;\/en\/privacy-policy\/&quot; target=&quot;_blank&quot;&gt;data management information&lt;\/a&gt; especially the parts on identification, contact, treatment and billing.' aria-invalid='false' aria-required=\"true\"> <span>From <a class=\"nyilatkozat_adatkezelesrol\" href=\"\/en\/privacy-policy\/\" target=\"_blank\">data management information<\/a> especially the parts on identification, contact, treatment and billing.<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-text-left centerBtn ff_submit_btn_wrapper ff_submit_btn_wrapper_custom'><button class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style wpf_has_custom_css\" type=\"submit\" name=\"custom_submit_button-16_13\" data-name=\"custom_submit_button-16_13\" tabindex=\"109\" >Send<\/button><style>form.fluent_form_16 .wpf_has_custom_css.ff-btn-submit { background-color:#1a7efb;border-color:#1a7efb;color:#ffffff;border-radius:6px;min-width:33%; }form.fluent_form_16 .wpf_has_custom_css.ff-btn-submit:hover { background-color:#ffffff;border-color:#1a7efb;color:#1a7efb;border-radius:6px;min-width:33%; } <\/style><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button tabindex='110'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form><div id='fluentform_16_errors' class='ff-errors-in-stack ff_form_instance_16_2 ff-form-loading_errors ff_form_instance_16_2_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_16_2 = 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