{"id":3088,"date":"2019-11-11T13:44:32","date_gmt":"2019-11-11T12:44:32","guid":{"rendered":"https:\/\/www.mmc.nl\/oncologie\/?page_id=3088"},"modified":"2019-11-11T13:45:05","modified_gmt":"2019-11-11T12:45:05","slug":"verwijsformulier-neuro-endocriene-tumoren","status":"publish","type":"page","link":"https:\/\/www.mmc.nl\/oncologie\/verwijsformulier-neuro-endocriene-tumoren\/","title":{"rendered":"Verwijsformulier Neuro endocriene tumoren"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_6_38'>Dit veld is bedoeld voor validatiedoeleinden en moet niet worden gewijzigd.<\/div><\/li><li id=\"field_6_3\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Personalia pati\u00ebnt<\/h2><\/li><li id=\"field_6_4\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_4'>Achternaam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_6_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_5\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Voorletters<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_6_5' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Geslacht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_6'>\n\t\t\t<li class='gchoice gchoice_6_6_0'>\n\t\t\t\t<input name='input_6' type='radio' value='man'  id='choice_6_6_0'    \/>\n\t\t\t\t<label for='choice_6_6_0' id='label_6_6_0' class='gform-field-label gform-field-label--type-inline'>man<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_6_1'>\n\t\t\t\t<input name='input_6' type='radio' value='vrouw'  id='choice_6_6_1'    \/>\n\t\t\t\t<label for='choice_6_6_1' id='label_6_6_1' class='gform-field-label gform-field-label--type-inline'>vrouw<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_6_2'>\n\t\t\t\t<input name='input_6' type='radio' value='overig'  id='choice_6_6_2'    \/>\n\t\t\t\t<label for='choice_6_6_2' id='label_6_6_2' class='gform-field-label gform-field-label--type-inline'>overig<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_7\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_7'>Geboortedatum<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_6_7' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dd-mm-yyyy' aria-describedby=\"input_6_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_7_date_format' class='screen-reader-text'>DD dash MM dash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_7' class='gform_hidden' value='https:\/\/www.mmc.nl\/oncologie\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>Adres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_6_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_9\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_9'>Telefoonnummer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_6_9' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_35\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_35'>BSN<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_6_35' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Verwijzer<\/h2><\/li><li id=\"field_6_2\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_2'>Datum verwijzing<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_6_2' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dag-maand-jaar' aria-describedby=\"input_6_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_2_date_format' class='screen-reader-text'>DD dash MM dash JJJJ<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_2' class='gform_hidden' value='https:\/\/www.mmc.nl\/oncologie\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_11\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_11'>Naam specialist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_6_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_12\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>Functie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_6_12' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_14\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_14'>Ziekenhuis<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_6_14' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Maak uw keuze<\/option><option value='CZE' >CZE<\/option><option value='Anna' >Anna<\/option><option value='Elkerliek' >Elkerliek<\/option><option value='Bernhoven' >Bernhoven<\/option><option value='Elders, namelijk' >Elders, namelijk<\/option><\/select><\/div><\/li><li id=\"field_6_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_6_15'><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_6_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_16\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Reden van verwijzing<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_16'>\n\t\t\t<li class='gchoice gchoice_6_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Overname behandeling'  id='choice_6_16_0'    \/>\n\t\t\t\t<label for='choice_6_16_0' id='label_6_16_0' class='gform-field-label gform-field-label--type-inline'>Overname behandeling<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='Second opinion'  id='choice_6_16_1'    \/>\n\t\t\t\t<label for='choice_6_16_1' id='label_6_16_1' class='gform-field-label gform-field-label--type-inline'>Second opinion<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_17\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_17'>Algemene voorgeschiedenis (kopieer\/plak hier eventueel uw laatste brief)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_6_17' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_18\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_18'>Oncologische voorgeschiedenis (kopieer\/plak hier eventueel uw laatste brief)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_6_18' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_20\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Radiologische onderzoeken<\/h2><div class='gsection_description' id='gfield_description_6_20'>Alle beeldvorming inclusief hard copy uitslagen moeten separaat worden verzonden.\n\n<\/div><\/li><li id=\"field_6_23\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_23'>Radiologieverslag<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_6_23' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_26\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_26'>PA-verslag<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_26' id='input_6_26' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_34\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><span style=\"font-size:10px\">Ingevulde gegevens worden gebruikt ten behoeve van de verwijzing van de pati&euml;nt. 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