{"id":705,"date":"2019-08-02T13:01:49","date_gmt":"2019-08-02T11:01:49","guid":{"rendered":"http:\/\/pihouse.pl\/?page_id=705"},"modified":"2019-08-02T13:27:53","modified_gmt":"2019-08-02T11:27:53","slug":"705-2","status":"publish","type":"page","link":"https:\/\/pihouse.pl\/en\/705-2\/","title":{"rendered":"Elementor #705"},"content":{"rendered":"<div data-elementor-type=\"wp-post\" data-elementor-id=\"705\" class=\"elementor elementor-705\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5f170e2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5f170e2\" data-element_type=\"section\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[{&quot;jet_parallax_layout_image&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;_id&quot;:&quot;e52d6a1&quot;,&quot;jet_parallax_layout_image_tablet&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_image_mobile&quot;:{&quot;url&quot;:&quot;&quot;,&quot;id&quot;:&quot;&quot;,&quot;size&quot;:&quot;&quot;},&quot;jet_parallax_layout_speed&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:50,&quot;sizes&quot;:[]},&quot;jet_parallax_layout_type&quot;:&quot;scroll&quot;,&quot;jet_parallax_layout_z_index&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x&quot;:50,&quot;jet_parallax_layout_bg_y&quot;:50,&quot;jet_parallax_layout_bg_size&quot;:&quot;auto&quot;,&quot;jet_parallax_layout_animation_prop&quot;:&quot;transform&quot;,&quot;jet_parallax_layout_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;],&quot;jet_parallax_layout_direction&quot;:null,&quot;jet_parallax_layout_fx_direction&quot;:null,&quot;jet_parallax_layout_bg_x_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_x_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_y_mobile&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_tablet&quot;:&quot;&quot;,&quot;jet_parallax_layout_bg_size_mobile&quot;:&quot;&quot;}]}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-b7c0c9b\" data-id=\"b7c0c9b\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6bea61a elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"6bea61a\" data-element_type=\"widget\" data-settings=\"{&quot;button_width&quot;:&quot;100&quot;,&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Nowy formularz\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"705\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"6bea61a\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"PI-House \u2013 Centrum Bada\u0144 Klinicznych\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-name elementor-col-100\">\n\t\t\t\t\t<span class=\"form-header\">Basic information<\/span>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5]\" id=\"form-field-field_5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-message elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-message\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tE-mail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[message]\" id=\"form-field-message\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"E-mail\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_1 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_1]\" id=\"form-field-field_1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Phone number\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_2 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_2]\" id=\"form-field-field_2\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Date of birth\" required=\"required\" aria-required=\"true\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4 elementor-col-100\">\n\t\t\t\t\t<span class=\"form-header\">Correspondence address<\/span>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_6 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPostcode\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_6]\" id=\"form-field-field_6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Postcode\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tplace\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7]\" id=\"form-field-field_7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"place\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tUlica, numer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3]\" id=\"form-field-field_3\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ulica, numer domu\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8 elementor-col-100\">\n\t\t\t\t\t<span class=\"form-text\">Ladies and Gentlemen, answering the questions contained in the survey below will allow us to choose the right diagnostic and medical consultation proposal for you. Participation in our free research programs is completely voluntary.<\/span>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you ever used the services of PI HOUSE Clinical Research Center?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_9-0\" name=\"form_fields[field_9]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_9-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_9-1\" name=\"form_fields[field_9]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_9-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_10 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_10\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had a documented heart attack or stroke?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_10-0\" name=\"form_fields[field_10]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_10-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_10-1\" name=\"form_fields[field_10]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_10-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_11 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_11\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes then when?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_11]\" id=\"form-field-field_11\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_12 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have atrial fibrillation? Do you therefore use medication?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_12-0\" name=\"form_fields[field_12]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_12-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_12-1\" name=\"form_fields[field_12]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_12-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_13 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_13\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, what?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_13]\" id=\"form-field-field_13\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_14 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_14\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had any heart surgery (or surgery): ballooning, stenting, bypass or coronanography?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_14-0\" name=\"form_fields[field_14]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_14-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_14-1\" name=\"form_fields[field_14]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_14-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_19 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_19\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes then when?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_19]\" id=\"form-field-field_19\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_16 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_16\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you use cholesterol medications (e.g. Roswera, Romazic, Zahron, Zaranta, Simvacard, Zocor, Tulip, Sortis, Atoris, Atrox, Torvalipin and others)?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_16-0\" name=\"form_fields[field_16]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_16-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_16-1\" name=\"form_fields[field_16]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_16-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_17 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_17\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, please indicate in what dose (mg)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_17]\" id=\"form-field-field_17\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_18 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_18\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have type 1 diabetes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_18-0\" name=\"form_fields[field_18]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_18-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_18-1\" name=\"form_fields[field_18]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_18-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_21 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_21\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, since when?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_21]\" id=\"form-field-field_21\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_20 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_20\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have type 2 diabetes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_20-0\" name=\"form_fields[field_20]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_20-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_20-1\" name=\"form_fields[field_20]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_20-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_27 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_27\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, since when?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_27]\" id=\"form-field-field_27\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_22 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_22\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you been diagnosed with atherosclerosis by Doppler ultrasound?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_22-0\" name=\"form_fields[field_22]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_22-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_22-1\" name=\"form_fields[field_22]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_22-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_23 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_23\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes then when ?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_23]\" id=\"form-field-field_23\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_24 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_24\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have hypertension?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_24-0\" name=\"form_fields[field_24]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_24-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_24-1\" name=\"form_fields[field_24]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_24-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_15 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_15\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, since when?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_15]\" id=\"form-field-field_15\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_25 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_25\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you been diagnosed with fatty liver or liver fibrosis?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_25-0\" name=\"form_fields[field_25]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_25-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_25-1\" name=\"form_fields[field_25]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_25-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_26 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_26\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have psoriasis? Lupus? Atopic Dermatitis? Acne?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_26-0\" name=\"form_fields[field_26]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_26-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_26-1\" name=\"form_fields[field_26]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_26-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_28 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_28\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, since when?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_28]\" id=\"form-field-field_28\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_29 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_29\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you been diagnosed with rheumatoid arthritis?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_29-0\" name=\"form_fields[field_29]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_29-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_29-1\" name=\"form_fields[field_29]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_29-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_30 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_30\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes then when ?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_30]\" id=\"form-field-field_30\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_31 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_31\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you currently take medication for rheumatoid arthritis, e.g. methotrexate?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_31-0\" name=\"form_fields[field_31]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_31-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_31-1\" name=\"form_fields[field_31]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_31-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_32 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_32\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you been diagnosed with Alzheimer&#039;s?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_32-0\" name=\"form_fields[field_32]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_32-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_32-1\" name=\"form_fields[field_32]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_32-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_33 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_33\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you been diagnosed with depression?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_33-0\" name=\"form_fields[field_33]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_33-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_33-1\" name=\"form_fields[field_33]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_33-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_34 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_34\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you suffer from bipolar disorder?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_34-0\" name=\"form_fields[field_34]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_34-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_34-1\" name=\"form_fields[field_34]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_34-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_35 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_35\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you been diagnosed with cancer?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_35-0\" name=\"form_fields[field_35]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_35-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_35-1\" name=\"form_fields[field_35]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_35-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_36 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_36\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, please provide the date of diagnosis and what type of cancer was it?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_36]\" id=\"form-field-field_36\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_37 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_37\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have any other diseases than those listed on the form, e.g. kidney diseases, joint diseases, thyroid disease, arrhythmia, peptic ulcer disease, osteoporosis, asthma, COPD, multiple sclerosis?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tak \" id=\"form-field-field_37-0\" name=\"form_fields[field_37]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_37-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nie\" id=\"form-field-field_37-1\" name=\"form_fields[field_37]\" required=\"required\" aria-required=\"true\"> <label for=\"form-field-field_37-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_38 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_38\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf yes, please specify which one?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_38]\" id=\"form-field-field_38\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_39 elementor-col-100\">\n\t\t\t\t\t<span class=\"form-header\">Please list all medications you are currently taking along with the doses:<\/span>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_40 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_40]\" id=\"form-field-field_40\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_45 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_45]\" id=\"form-field-field_45\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_42 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_42]\" id=\"form-field-field_42\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_44 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_44]\" id=\"form-field-field_44\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_46 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_46]\" id=\"form-field-field_46\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_57 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_57]\" id=\"form-field-field_57\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_56 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_56]\" id=\"form-field-field_56\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_55 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_55]\" id=\"form-field-field_55\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_54 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_54]\" id=\"form-field-field_54\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_53 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_53]\" id=\"form-field-field_53\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_52 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_52]\" id=\"form-field-field_52\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_51 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_51]\" id=\"form-field-field_51\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_50 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_50]\" id=\"form-field-field_50\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_49 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_49]\" id=\"form-field-field_49\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_48 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_48]\" id=\"form-field-field_48\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_47 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_47]\" id=\"form-field-field_47\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_43 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_43]\" id=\"form-field-field_43\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Drug Name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_41 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_41]\" id=\"form-field-field_41\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dose\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_58 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_58\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow did you find out about today&#039;s action:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Plakaty, ulotki\" id=\"form-field-field_58-0\" name=\"form_fields[field_58]\"> <label for=\"form-field-field_58-0\">Posters, leaflets<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Internet\" id=\"form-field-field_58-1\" name=\"form_fields[field_58]\"> <label for=\"form-field-field_58-1\">Internet<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Radio\" id=\"form-field-field_58-2\" name=\"form_fields[field_58]\"> <label for=\"form-field-field_58-2\">Radio<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_59 elementor-col-100\">\n\t\t\t\t\t<span class=\"form-text\">\nI consent to the processing of my personal data, including sensitive data, based on the GDPR Art. 6 point a. in order to protect my health, provide medical services to me and conduct medical clinical trials by the Centrum Bada\u0144 Klinicznych PI-House sp. z o.o. with headquarters in Gda\u0144sk, ul. Na Zaspa 3. Consent to the processing of my personal data also includes consent to their processing in the future, provided that the purpose of processing does not change. I have been informed about the right to view and correct data and to obtain information on the data collected. At the same time, I agree to the use of my data, including sensitive data, to: inform me about the possibility of participating in free preventive examinations, assessing the possibility of qualifying me for clinical tests and inviting me to participate in such examination. I agree to receive information about the offer of preventive tests or clinical tests and about upcoming visits to the PI-House Clinical Research Center with the use of means of distance communication in the form of telephone contact, email, sms or written notification addressed to the address I provided. I consent to the processing of my data for the purposes and scope indicated in this consent in IT systems.\n<\/span>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">SEND<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Elementor #705 - PI-House \u2013 Centrum Bada\u0144 Klinicznych<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/pihouse.pl\/en\/705-2\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Elementor #705 - PI-House \u2013 Centrum Bada\u0144 Klinicznych\" \/>\n<meta property=\"og:url\" content=\"https:\/\/pihouse.pl\/en\/705-2\/\" \/>\n<meta property=\"og:site_name\" content=\"PI-House \u2013 Centrum Bada\u0144 Klinicznych\" \/>\n<meta property=\"article:modified_time\" content=\"2019-08-02T11:27:53+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/pihouse.pl\/705-2\/\",\"url\":\"https:\/\/pihouse.pl\/705-2\/\",\"name\":\"Elementor #705 - PI-House \u2013 Centrum Bada\u0144 Klinicznych\",\"isPartOf\":{\"@id\":\"https:\/\/pihouse.pl\/#website\"},\"datePublished\":\"2019-08-02T11:01:49+00:00\",\"dateModified\":\"2019-08-02T11:27:53+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/pihouse.pl\/705-2\/#breadcrumb\"},\"inLanguage\":\"en-GB\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/pihouse.pl\/705-2\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/pihouse.pl\/705-2\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Strona g\u0142\u00f3wna\",\"item\":\"https:\/\/pihouse.pl\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Elementor #705\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/pihouse.pl\/#website\",\"url\":\"https:\/\/pihouse.pl\/\",\"name\":\"PI-House \u2013 Centrum Bada\u0144 Klinicznych\",\"description\":\"W okresie naszej dzia\u0142alno\u015bci przeprowadzili\u015bmy wiele bada\u0144 klinicznych. 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