Rezeptanforderung

{"url":"\/rezeptanforderung","form_action_on_submit":"display_text","form_action_on_submit_text":"Vielen Dank f\u00fcr das Einreichen des Formulars.","form_include_text_fields_in_notification_emails":"1","rows":[{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-15","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-15","field_type":"text","text":"<p>Patientendaten (Pflichtangaben)<\/p>"}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-13","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-13","field_type":"line"}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-2","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-2","field_type":"title","field_label":"Anrede","field_placeholder":"Ausw\u00e4hlen","clientField":"title"}]},{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-5","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-5","field_type":"spacer","height":"67px"}]}]},{"columns":[{"columnWidth":12,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-3","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-3","field_type":"firstname","field_label":"Vorname","field_placeholder":"Vorname","clientField":"firstname"}]},{"columnWidth":12,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-4","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-4","field_type":"lastname","field_label":"Nachname","field_placeholder":"Nachname","clientField":"lastname"}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-6","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-6","field_type":"birthdate","field_label":"Geburtsdatum","field_placeholder":"Geburtsdatum","clientField":"birthdate"}]},{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-7","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-7","field_type":"phone","field_label":"Telefonnummer f\u00fcr R\u00fcckfragen","field_placeholder":"","clientField":"phone","field_required":"1","field_label_required_error":"","field_hidden":null}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-8","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-8","field_type":"email","field_label":"E-Mail","field_placeholder":"E-Mail","clientField":"email"}]}]},{"columns":[{"columnWidth":16,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-9","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-9","field_type":"street","field_label":"Stra\u00dfe","field_placeholder":"Stra\u00dfe","clientField":"street"}]},{"columnWidth":8,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-10","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-10","field_type":"streetnr","field_label":"Hausnummer","field_placeholder":"Hausnummer","clientField":"streetnr"}]}]},{"columns":[{"columnWidth":8,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-11","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-11","field_type":"zipcode","field_label":"Postleitzahl","field_placeholder":"Postleitzahl","clientField":"zipcode"}]},{"columnWidth":16,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-12","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-12","field_type":"city","field_label":"Stadt","field_placeholder":"Stadt","clientField":"city"}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-16","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-16","field_type":"line"}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-17","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-17","field_type":"text","text":"<p>Versicherungs-und Behandlungsdaten<\/p>"}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-18","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-18","field_type":"radio","field_label":"Krankenversicherung","field_placeholder":"","field_required":"1","field_label_required_error":"","field_hidden":null,"field_select_multiple":null,"field_label_no_option":"","options":[{"option_label":"gesetzlich","option_value":"","option_selected":false,"option_assigned_groups":null},{"option_label":"privat","option_value":"","option_selected":false,"option_assigned_groups":null},{"option_label":"Selbstzahler","option_value":"","option_selected":false,"option_assigned_groups":null}]}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-19","field_name":"Name der Krankenkasse","field_type":"input_text","field_label":"Name der Krankenkasse","field_placeholder":"","field_required":"1","field_label_required_error":"","field_hidden":null}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-20","field_name":"Behandelnde\/r Arzt\/\u00c4rztin (Hausarzt, Facharzt), sofern mehrere mit Ihnen zusammenarbeiten","field_type":"input_text","field_label":"Behandelnde\/r Arzt\/\u00c4rztin (Hausarzt, Facharzt), sofern mehrere mit Ihnen zusammenarbeiten","field_placeholder":"Text","field_required":"1","field_label_required_error":"","field_hidden":null}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-25","field_name":"Teilen Sie uns mit, was Sie ben\u00f6tigen!","field_type":"input_text","field_label":"Teilen Sie uns mit, was Sie ben\u00f6tigen!","field_placeholder":"","field_required":"1","field_label_required_error":"","field_hidden":null}]}]},{"columns":[{"columnWidth":null,"fields":[{"field_id":"493c6e74-626d-4416-ba6c-ae8780faef54-field-1","field_name":"493c6e74-626d-4416-ba6c-ae8780faef54-field-1","field_type":"button","field_label":"Absenden","buttonClasses":"wsw-block-button-default wsw-button-solid wsw-button-pill wsw-button-meduim"}]}]}]}

{"no_option":"Keine Option","subscribe_to_newsletter":"Newsletter abonnieren","subscribe_to_newsletter_yes":"Ja","subscribe_to_newsletter_no":"Nein","send_form_to_me_label":"Kopie an mich senden","choose_file":"Datei ausw\u00e4hlen","invalid_email":"E-Mail ist nicht korrekt","email_does_not_match":"E-Mail stimmt nicht \u00fcberein","password_does_not_match":"Passwort stimmt nicht \u00fcberein","captcha_failed":"Captcha-Verifikation fehlgeschlagen. Bitte versuchen Sie es erneut.","field_required":"Dieses Feld ist notwendig","unknown_error":"Unbekannter Error. Bitte neu laden","on_submit_text":"Vielen Dank f\u00fcr das Einreichen des Formulars."}