{"id":18462,"date":"2023-02-27T14:15:18","date_gmt":"2023-02-27T13:15:18","guid":{"rendered":"https:\/\/qualiphar.be\/?page_id=18462"},"modified":"2023-02-28T09:02:53","modified_gmt":"2023-02-28T08:02:53","slug":"reporting-a-side-effect","status":"publish","type":"page","link":"https:\/\/qualiphar.be\/en\/reporting-a-side-effect\/","title":{"rendered":"Reporting a side effect"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.16&#8243; custom_padding=&#8221;20px||||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text admin_label=&#8221;titel &#8211; Onze producten&#8221; _builder_version=&#8221;4.19.4&#8243; _dynamic_attributes=&#8221;content&#8221; global_colors_info=&#8221;{}&#8221;]@ET-DC@eyJkeW5hbWljIjp0cnVlLCJjb250ZW50IjoicG9zdF90aXRsZSIsInNldHRpbmdzIjp7ImJlZm9yZSI6IjxoMT4iLCJhZnRlciI6IjwvaDE+In19@[\/et_pb_text][et_pb_text _builder_version=&#8221;4.19.5&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>All medications have side effects and must have a package leaflet. A side effect is an unwanted or medical incident in a patient receiving treatment with a medication or medical preparation that is not necessarily related to the treatment. The most common side effects are already known from clinical studies. We only discover certain side effects after many different people take a medication. Side effects may occur only after long-term use of the medication. And sometimes side effects occur when a medication is used in combination with other medications.<\/p>\n<p>Dietary supplements are covered by <a href=\"https:\/\/www.health.belgium.be\/en\/node\/22912\" target=\"_blank\" rel=\"noopener\">food legislation<\/a> because these are legally considered food. For dietary supplements, package leaflets are not required. Nevertheless, unwanted reactions may also occur.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; _builder_version=&#8221;4.19.4&#8243; custom_padding=&#8221;0px||||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.16&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text admin_label=&#8221;subtitel&#8221; _builder_version=&#8221;4.19.5&#8243; text_font=&#8221;Rubrik SemiBold|100|||||||&#8221; text_font_size=&#8221;26px&#8221; text_line_height=&#8221;1.72em&#8221; header_3_line_height=&#8221;1.2em&#8221; custom_padding=&#8221;|50px|||false|false&#8221; text_font_size_phone=&#8221;20px&#8221; text_font_size_last_edited=&#8221;off|tablet&#8221; header_3_font_size_tablet=&#8221;&#8221; header_3_font_size_phone=&#8221;20px&#8221; header_3_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>The importance of reporting a side effect<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.19.5&#8243; custom_margin=&#8221;||40px||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>Qualiphar monitors medication safety by collecting and investigating all spontaneous reports from patients or care providers. We also have a statutory duty to collect and anonymise all details in an international database. All countries collect information on medication side effects in this international database. As a pharmaceutical company, we are regularly audited by the <a href=\"https:\/\/www.famhp.be\/en\/reporting_a_side_effect_as_a_patient\" target=\"_blank\" rel=\"noopener\">Federal Agency for Medicines and Health Products (FAMHP)<\/a>. This means we must always report your side effect.<\/p>\n<p>[\/et_pb_text][et_pb_text admin_label=&#8221;subtitel&#8221; _builder_version=&#8221;4.19.5&#8243; text_font=&#8221;Rubrik SemiBold|100|||||||&#8221; text_font_size=&#8221;26px&#8221; text_line_height=&#8221;1.72em&#8221; header_3_line_height=&#8221;1.2em&#8221; header_3_font_size_tablet=&#8221;&#8221; header_3_font_size_phone=&#8221;20px&#8221; header_3_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>How do I report a side effect?<\/h3>\n<p>[\/et_pb_text][et_pb_text admin_label=&#8221;Tekst&#8221; _builder_version=&#8221;4.19.5&#8243; custom_margin=&#8221;||40px||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p>To help us process your information quickly and effectively, please submit as much relevant information as possible using <a href=\"#contactform\">the form below<\/a>. You should provide at least the following information:<\/p>\n<ul>\n<li>The contact details of the person making the report.<\/li>\n<li>The initials of the person who experienced the possible side effect and\/or other personal details, such as gender and date of birth.<\/li>\n<li>The name of Qualiphar\u2019s medication or product.<\/li>\n<li>A description of the possible side effect, such as the symptoms experienced, the date when the possible side effect first occurred and the outcome of the possible side effect.<\/li>\n<\/ul>\n<p>[\/et_pb_text][et_pb_text admin_label=&#8221;subtitel&#8221; _builder_version=&#8221;4.19.5&#8243; text_font=&#8221;Rubrik SemiBold|100|||||||&#8221; text_font_size=&#8221;26px&#8221; text_line_height=&#8221;1.72em&#8221; header_3_line_height=&#8221;1.2em&#8221; header_3_font_size_tablet=&#8221;&#8221; header_3_font_size_phone=&#8221;20px&#8221; header_3_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>What happens to your report?<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.19.5&#8243; custom_margin=&#8221;||40px||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<ol>\n<li>Our colleagues in the pharmacovigilance department collect, record, and analyse each individual report.<\/li>\n<li>When a side effect is reported, Qualiphar may collect certain personal data. You can find more information on this in the <a href=\"https:\/\/qualiphar.be\/en\/privacy-policy\/\">privacy policy<\/a>. Every side effect is uploaded into the international database and reviewed there by the authorities.<\/li>\n<li>Experts evaluate those side effects so that action can be taken where necessary, for example by adjusting the package leaflet or alerting care providers.<\/li>\n<\/ol>\n<p>If you have any questions about side effects of Qualiphar products, you are welcome to <a href=\"https:\/\/qualiphar.be\/en\/contact-us\/\">contact Qualiphar directly<\/a>. You may also report the side effect directly to the Federal Agency for Medicines and Health Products (FAMHP) by visiting <a href=\"https:\/\/www.fagg.be\/nl\/bijwerking\" target=\"_blank\" rel=\"noopener\">www.eenbijwerkingmelden.be<\/a>.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row disabled_on=&#8221;off|off|off&#8221; module_id=&#8221;contactform&#8221; _builder_version=&#8221;4.19.5&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#efefef&#8221; custom_padding=&#8221;|75px||75px|false|true&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.19.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][de_fb_form title=&#8221;Reporting a side effect&#8221; scrollto_form_after_submit=&#8221;off&#8221; redirect_after_success=&#8221;on&#8221; redirect_url_after_submission=&#8221;@ET-DC@eyJkeW5hbWljIjp0cnVlLCJjb250ZW50IjoicG9zdF9saW5rX3VybF9wYWdlIiwic2V0dGluZ3MiOnsicG9zdF9pZCI6IjE3OTgyIn19@&#8221; failed_message=&#8221;Please fill out the form correctly%%message%%&#8221; use_custom_email=&#8221;off&#8221; custom_contact_email=&#8221;pharmacovigilance@qualiphar.com&#8221; from_name=&#8221;custom&#8221; custom_from_name=&#8221;Pharmacovigilance Qualiphar&#8221; from_email=&#8221;custom&#8221; custom_from_email=&#8221;pharmacovigilance@qualiphar.com&#8221; send_copy_to_sender=&#8221;on&#8221; sender_email_field=&#8221;4&#8243; reply_from_name=&#8221;custom&#8221; reply_custom_from_name=&#8221;Pharmacovigilance Qualiphar&#8221; reply_from_email=&#8221;custom&#8221; reply_custom_from_email=&#8221;pharmacovigilance@qualiphar.com&#8221; reply_to_name=&#8221;Pharmacovigilance Qualiphar&#8221; reply_to_email=&#8221;pharmacovigilance@qualiphar.com&#8221; reply_email_title=&#8221;Melding bijwerking Qualiphar product&#8221; radio_checkbox_checked_color=&#8221;#000000&#8243; multistep_enabled=&#8221;on&#8221; multistep_form_transition=&#8221;none&#8221; multistep_progress_bar_style=&#8221;lollipop&#8221; multistep_progress_bar_inactive_color=&#8221;#FFFFFF&#8221; multistep_show_progress_bar_percentage=&#8221;on&#8221; use_honeypot_captcha=&#8221;off&#8221; _builder_version=&#8221;4.19.5&#8243; _dynamic_attributes=&#8221;redirect_url_after_submission&#8221; _module_preset=&#8221;default&#8221; form_field_background_color=&#8221;#FFFFFF&#8221; form_field_text_color=&#8221;#000000&#8243; label_text_text_color=&#8221;#000000&#8243; custom_button=&#8221;on&#8221; button_text_color=&#8221;#FFFFFF&#8221; button_bg_color=&#8221;#00574a&#8221; button_border_color=&#8221;RGBA(255,255,255,0)&#8221; button_border_radius=&#8221;5px&#8221; custom_previous_step_button=&#8221;on&#8221; previous_step_button_text_color=&#8221;#FFFFFF&#8221; previous_step_button_bg_color=&#8221;#53af32&#8243; previous_step_button_border_color=&#8221;RGBA(255,255,255,0)&#8221; previous_step_button_border_radius=&#8221;5px&#8221; previous_step_button_icon=&#8221;&#x44;||divi||400&#8243; previous_step_button_icon_color=&#8221;#FFFFFF&#8221; previous_step_button_icon_placement=&#8221;left&#8221; previous_step_button_on_hover=&#8221;off&#8221; custom_next_step_button=&#8221;on&#8221; next_step_button_text_color=&#8221;#FFFFFF&#8221; next_step_button_bg_color=&#8221;#53af32&#8243; next_step_button_border_color=&#8221;RGBA(255,255,255,0)&#8221; next_step_button_border_radius=&#8221;5px&#8221; next_step_button_icon=&#8221;&#x45;||divi||400&#8243; next_step_button_icon_color=&#8221;#FFFFFF&#8221; next_step_button_on_hover=&#8221;off&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<div class=\"et_pb_module de_fb_form_field de_fb_form_field_0 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_melder_fk_0_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Reporter contact details<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_1 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_1_fk_1_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_1_fk_1\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. 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Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. 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Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_5\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_5\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Patient\" data-id=\"Patient\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"General practitioner\" data-id=\"General practitioner\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Specialist\" data-id=\"Specialist\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Chemist\" data-id=\"Chemist\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Nurse\" data-id=\"Nurse\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_6 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_5-andere_fk_6_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"5-Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_5-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_5-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_5-andere\" id=\"de_fb_5-andere_fk_6\" data-calc_default=\"0\" placeholder=\"Geben Sie bitte Ihre Antwort ein\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_7 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_8 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_pati\u00ebnt_fk_8_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Patient details<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_9 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_6_fk_9_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_6_fk_9\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_6\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_6\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_6\" id=\"de_fb_6_fk_9\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_10 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_7_fk_10_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_7_fk_10\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_7\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_7\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_7_fk_10_10_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_7\" value=\"M\" data-id=\"M\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_7_fk_10_10_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_7_fk_10_10_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_7\" value=\"F\" data-id=\"F\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_7_fk_10_10_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_7_fk_10_10_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_7\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_7_fk_10_10_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_11 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_7-andere_fk_11_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"7 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_7-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_7-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_7-andere\" id=\"de_fb_7-andere_fk_11\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_12 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_8_fk_12_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_8_fk_12\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_8\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_8\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_8\" id=\"de_fb_8_fk_12\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_13 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_9_fk_13_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_9_fk_13\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_9\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_9\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_9_fk_13_13_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_9\" value=\"Yes\" data-id=\"Yes\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_9_fk_13_13_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_9_fk_13_13_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_9\" value=\"No\" data-id=\"No\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_9_fk_13_13_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_9_fk_13_13_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_9\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_9_fk_13_13_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_14 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_9-andere_fk_14_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"9 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_9-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_9-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_9-andere\" id=\"de_fb_9-andere_fk_14\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_15 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_16 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_voorschrijver_fk_16_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Gegegevens voorschrijver<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_17 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_go_on_fk_17_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<p><strong>Please, press \"next\"<\/strong><\/p>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_18 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_10_fk_18_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_10_fk_18\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_10\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_10\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_10\" id=\"de_fb_10_fk_18\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_19 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_11_fk_19_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_11_fk_19\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_11\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_11\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_11\" id=\"de_fb_11_fk_19\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_20 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_12_fk_20_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_12_fk_20\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_12\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_12\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_12_fk_20_20_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_12\" value=\"General practitioner\" data-id=\"General practitioner\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_12_fk_20_20_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_12_fk_20_20_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_12\" value=\"Specialist\" data-id=\"Specialist\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_12_fk_20_20_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_12_fk_20_20_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_12\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_12_fk_20_20_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_21 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_12-andere_fk_21_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"12 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_12-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_12-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_12-andere\" id=\"de_fb_12-andere_fk_21\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_22 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_13_fk_22_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_13_fk_22\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_13\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_13\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_13\" id=\"de_fb_13_fk_22\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"  pattern=\"[0-9\\s]*\"  class=\"divi-form-builder-field input-field \"  value=\"\"  data-msg-pattern=\"Invalid Format.\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_23 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_14_fk_23_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_14_fk_23\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_14\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_14\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_14\" id=\"de_fb_14_fk_23\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_24 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_15_fk_24_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_15_fk_24\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_15\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_15\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_15_fk_24_24_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_15\" value=\"Yes\" data-id=\"Yes\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_15_fk_24_24_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_15_fk_24_24_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_15\" value=\"No\" data-id=\"No\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_15_fk_24_24_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_25 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_26 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_geneesmiddel_fk_26_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Medication \/ Product<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_27 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_16_fk_27_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_16_fk_27\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_16\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_16\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_16\" id=\"de_fb_16_fk_27\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_28 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_17_fk_28_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_17_fk_28\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_17\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_17\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Tablet\" data-id=\"Tablet\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Liquid form\" data-id=\"Liquid form\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Ointment\" data-id=\"Ointment\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Powder\" data-id=\"Powder\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_29 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_17-andere_fk_29_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"17 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_17-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_17-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_17-andere\" id=\"de_fb_17-andere_fk_29\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_30 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_18_fk_30_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_18_fk_30\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"datepicker\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_18\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_18\"\/>\t\t\t\t\t\t\r\n\t\t\t\t<span class=\"datepicker-wrapper\">\r\n\t\t\t\t\t<input type=\"text\" class=\"divi-form-builder-field datepicker-field\"  name=\"de_fb_18\" id=\"de_fb_18_fk_30\" placeholder=\"Voer uw antwoord in\" value=\"\"  autocomplete=\"on\" acf-date=\"\"\/>\r\n\t\t\t\t<\/span>\r\n\r\n\t\t\t\t<script>\r\n\t\t\t\t\tjQuery(document).ready(function($){\r\n\t\t\t\t\t\tvar datepicker_option = $.extend(\r\n\t\t\t\t\t\t\t{},\r\n\t\t\t\t\t\t\t$.datepicker.regional['nl'],\r\n\t\t\t\t\t\t\t{\r\n\t\t\t\t\t\t\t\tshowOn: \"both\",\r\n\t\t\t\t\t            \/\/buttonImage: datepicker_arg.img_url,\r\n\t\t\t\t\t            buttonImage: 'https:\/\/qualiphar.be\/wp-content\/plugins\/divi-form-builder\/images\/calendar.png',\r\n\t\t\t\t\t            buttonImageOnly: true,\r\n\t\t\t\t\t            buttonText: \"Select date\",\r\n\t\t\t\t\t            changeYear: true,\r\n\t\t\t\t\t\t\t\t\tyearRange: '1950:2050',\r\n\t\t\t\t\t            changeMonth: true,\r\n\t\t\t\t\t            dateFormat: \"dd-mm-yy\",\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t            beforeShow: function(input, inst) {\r\n\t\t\t\t\t\t\t\t\tvar $dp = $('#ui-datepicker-div');\r\n\t\t\t\t\t\t\t\t\t$dp.addClass(\"date_picker_30\");\r\n\t\t\t\t\t\t\t\t\t\/\/ Ensure calendar is above tab modules, sticky headers, and builder overlays (see stacking contexts).\r\n\t\t\t\t\t\t\t\t\t$dp.css('z-index', 2147483646);\r\n\t\t\t\t\t\t\t\t\tif (inst && inst.dpDiv && inst.dpDiv.length) {\r\n\t\t\t\t\t\t\t\t\t\tinst.dpDiv.css('z-index', 2147483646);\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t},\r\n\t\t\t\t\t\t\t\tonClose: function(dateText, inst ) {\r\n\t\t\t\t\t\t\t\t\t$('#ui-datepicker-div').removeClass(\"date_picker_30\");\r\n\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\tdocument.getElementById(\"de_fb_18_fk_30\").dispatchEvent(new Event('change'));\r\n\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t);\r\n\t\t\t\t\t\t\t\t$('#de_fb_18_fk_30').datepicker( datepicker_option );\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t});\r\n\t\t\t\t<\/script>\r\n\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_31 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_19_fk_31_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_19_fk_31\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t\t<span class=\"df_field_description_text\">What dose of the Qualiphar medication was used?<\/span>\r\n\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_19\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_19\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_19\" id=\"de_fb_19_fk_31\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_32 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_20_fk_32_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_20_fk_32\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t\t<span class=\"df_field_description_text\">See packaging<\/span>\r\n\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_20\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_20\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_20\" id=\"de_fb_20_fk_32\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_33 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_21_fk_33_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_21_fk_33\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_21\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_21\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_21\" id=\"de_fb_21_fk_33\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_34 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_35 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_bijwerking_fk_35_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Side effect<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_36 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_22_fk_36_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_22_fk_36\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_22\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_22\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Side effect\" data-id=\"Side effect\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Transmission of infection\" data-id=\"Transmission of infection\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Exposure during pregnancy or breastfeeding (also without side effects)\" data-id=\"Exposure during pregnancy or breastfeeding (also without side effects)\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Incorrect use\" data-id=\"Incorrect use\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Abuse and\/or dependency\" data-id=\"Abuse and\/or dependency\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Medication error\" data-id=\"Medication error\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_6\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Overdosis\" data-id=\"Overdosis\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_6\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Overdosis<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_7\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Occupational exposure\" data-id=\"Occupational exposure\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_7\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Beroepsblootstelling<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_8\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Lack of efficacy\" data-id=\"Lack of efficacy\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_8\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Gebrek aan werkzaamheid<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_9\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_9\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_37 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_22-andere_fk_37_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"22 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_22-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_22-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_22-andere\" id=\"de_fb_22-andere_fk_37\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_38 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_23_fk_38_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_23_fk_38\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_23\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_23\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_23\" id=\"de_fb_23_fk_38\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_39 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_24_fk_39_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_24_fk_39\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_24\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_24\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"No\" data-id=\"No\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Hospitalisation (or prolonging the stay)\" data-id=\"Hospitalisation (or prolonging the stay)\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Permanent disability or invalidity\" data-id=\"Permanent disability or invalidity\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Life-threatening\" data-id=\"Life-threatening\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Congenital abnormalities\" data-id=\"Congenital abnormalities\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Other serious abnormalities?\" data-id=\"Other serious abnormalities?\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_6\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_6\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Overdosis<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_40 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_24-andere_fk_40_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"24 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_24-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_24-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_24-andere\" id=\"de_fb_24-andere_fk_40\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_41 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_25_fk_41_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_25_fk_41\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_25\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_25\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Discontinued\" data-id=\"Discontinued\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Temporarily suspended\" data-id=\"Temporarily suspended\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Dose reduced\" data-id=\"Dose reduced\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Dose increased\" data-id=\"Dose increased\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Unchanged\" data-id=\"Unchanged\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Unknown\" data-id=\"Unknown\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_6\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Other\" data-id=\"Other\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_6\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Overdosis<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_42 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_25-andere_fk_42_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"25 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_25-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_25-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_25-andere\" id=\"de_fb_25-andere_fk_42\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_43 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_26_fk_43_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_26_fk_43\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_26\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_26\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_26\" id=\"de_fb_26_fk_43\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_44 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_27_fk_44_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_27_fk_44\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_27\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_27\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_27\" id=\"de_fb_27_fk_44\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_45 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_28_fk_45_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_28_fk_45\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_28\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_28\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_28_fk_45_45_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_28\" value=\"Qualiphar may contact me about this side effect\" data-id=\"Qualiphar may contact me about this side effect\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_28_fk_45_45_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_28_fk_45_45_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_28\" value=\"I do not want Qualiphar to contact me about this side effect.\" data-id=\"I do not want Qualiphar to contact me about this side effect.\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_28_fk_45_45_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_46 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_privacy_fk_46_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Privacy statement<\/h3>\n<p>The information requested on this page can help us better identify medication-related risks. This is important for monitoring the quality and safety of our products. The details you enter contain personal information. This information will be kept strictly confidential. Your personal details will be placed in a database and forwarded anonymously to the authorities that must be informed about all possible side effects of medications. Except for the government, your data will not be provided to third parties and will not be used for commercial purposes.<\/p>\n<p>(i) Providing the patient\u2019s gender and date of birth allows us to check whether we may have also received the same notification from their doctor, dispensing chemist, etc.<\/p>\n<p>(ii) To process a side effect, we need information about the person making the report (the reporter). We need this information to answer any question you asked.<\/p>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_47 dfb_radio_default clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_30_fk_47_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"checkbox\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_30\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_30\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\" id=\"et_pb_contact_de_fb_30_fk_47_47_0\" class=\"divi-form-builder-field checkbox-field\" name=\"de_fb_30[]\" value=\"I agree with the privacy statement\" data-id=\"I agree with the privacy statement\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_30_fk_47_47_0\">\r\n\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t<span>Ik ga akkoord met de privacy verklaring*<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div>[\/de_fb_form][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>All medications have side effects and must have a package leaflet. A side effect is an unwanted or medical incident in a patient receiving treatment with a medication or medical preparation that is not necessarily related to the treatment. The most common side effects are already known from clinical studies. We only discover certain side [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-18462","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Reporting a side effect - Qualiphar<\/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:\/\/qualiphar.be\/en\/reporting-a-side-effect\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Reporting a side effect - Qualiphar\" \/>\n<meta property=\"og:description\" content=\"Voorschriftvrije geneesmiddelen Ontsmetting van huid, oppervlakken en materialen Product CEDIUM\u00ae BENZALKONIUM druppels 30 ml Bijsluiter raadplegen CEDIUM\u00ae BENZALKONIUM spray 50 ml Bijsluiter raadplegen CEDIUM\u00ae IODINE DERM. druppels 30 ml Bijsluiter raadplegen CEDIUM\u00ae IODINE zalf 23 g Bijsluiter raadplegen NEO-SABENYL\u00ae 200 ml Bijsluiter raadplegen NEO-SABENYL\u00ae 10 l Bijsluiter raadplegen CEDIUM\u00ae CHLORHEXIDINI 0,05 % 10 ml x [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/qualiphar.be\/en\/reporting-a-side-effect\/\" \/>\n<meta property=\"og:site_name\" content=\"Qualiphar\" \/>\n<meta property=\"article:modified_time\" content=\"2023-02-28T08:02:53+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"8 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/qualiphar.be\\\/en\\\/reporting-a-side-effect\\\/\",\"url\":\"https:\\\/\\\/qualiphar.be\\\/en\\\/reporting-a-side-effect\\\/\",\"name\":\"Reporting a side effect - 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