temp2.maih.ch
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https://temp2.maih.ch/
Submission: On November 27 via api from US — Scanned from CH
Submission: On November 27 via api from US — Scanned from CH
Form analysis 2 forms found in the DOM
Name: cf2 — POST #
<form name="cf2" id="cf2" method="post" action="#">
<div class="cf-form-wrap cf-col-16 " style="background-color:none">
<div class="cf-response"></div>
<div class="cf-fields">
<div class="cf-control-group " data-key="5" data-name="html_5" data-label="HTML" data-type="html">
<div class="cf-control-input">
<div> Wir bitte Sie, die bestellten Medikamente innert zehn Tagen abzuholen.</div>
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="1" data-name="text_name" data-label="Name" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_textname"> Name <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_name]" id="form2_textname" aria-label="Name" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="7" data-name="text_vorname" data-label="Vorname" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_textvorname"> Vorname <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_vorname]" id="form2_textvorname" aria-label="Vorname" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="8" data-name="datum_geburt" data-label="Geburtsdatum" data-type="datetime" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_datumgeburt"> Geburtsdatum <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[datum_geburt]" id="form2_datumgeburt" required="" aria-required="true" autocomplete="off" class="cf-input flatpickr-input">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="0" data-name="text_email" data-label="Email" data-type="email" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_textemail"> Email <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="email" name="cf[text_email]" id="form2_textemail" aria-label="Email" required="" aria-required="true" placeholder="Enter your email address" class="cf-input ">
</div>
</div>
<div class="cf-control-group " data-key="3" data-name="html_3" data-label="Medikament1" data-type="html">
<div class="cf-control-input">
<div>
<h3>Medikament 1</h3>
</div>
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="9" data-name="text_medikamentenname1" data-label="Name des Medikaments" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_textmedikamentenname1"> Name des Medikaments <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_medikamentenname1]" id="form2_textmedikamentenname1" aria-label="Name des Medikaments" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="11" data-name="text_dosis1" data-label="Dosis" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_textdosis1"> Dosis <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_dosis1]" id="form2_textdosis1" aria-label="Dosis" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="13" data-name="dropdown_verabreichung1" data-label="Verabreichungsform" data-type="dropdown" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_dropdownverabreichung1"> Verabreichungsform <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<div class="cf-select cf-one-half">
<select name="cf[dropdown_verabreichung1]" id="form2_dropdownverabreichung1" aria-label="Verabreichungsform" required="" aria-required="true" class="cf-input cf-one-half ">
<option value="Tablette" data-calc-value="Tablette"> Tablette </option>
<option value="Kapsel" data-calc-value="Kapsel"> Kapsel </option>
<option value="Sirup" data-calc-value="Sirup"> Sirup </option>
<option value="Spritzen" data-calc-value="Spritzen"> Spritzen </option>
<option value="Anderes" data-calc-value="Anderes"> Anderes </option>
</select>
</div>
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="15" data-name="text_anderes1" data-label="Anderes nämlich" data-type="text" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textanderes1"> Anderes nämlich </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_anderes1]" id="form2_textanderes1" aria-label="Anderes nämlich" class="cf-input cf-one-half " aria-required="false">
</div>
</div>
<div class="cf-control-group " data-key="28" data-name="html_28" data-label="break" data-type="html">
<div class="cf-control-input">
<div> --</div>
</div>
</div>
<div class="cf-control-group cf-one-fourth" data-key="10" data-name="text_pckgroesse1" data-label="Packungsgrösse" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_textpckgroesse1"> Packungsgrösse <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_pckgroesse1]" id="form2_textpckgroesse1" aria-label="Packungsgrösse" required="" aria-required="true" class="cf-input cf-one-half ">
</div>
</div>
<div class="cf-control-group cf-one-fourth" data-key="12" data-name="text_anzahl1" data-label="Anzahl Packungen" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form2_textanzahl1"> Anzahl Packungen <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_anzahl1]" id="form2_textanzahl1" aria-label="Anzahl Packungen" required="" aria-required="true" class="cf-input cf-one-half ">
</div>
</div>
<div class="cf-control-group " data-key="29" data-name="checkbox_01" data-type="checkbox" data-required="">
<div class="cf-control-input">
<div class="cf-list ">
<div class="cf-checkbox-group cf-checkbox-group-required ">
<input type="checkbox" name="cf[checkbox_01][]" id="form2_checkbox01_0" value="weiteres Medikament" data-calc-value="weiteres Medikament" required="" aria-required="true" class="cf-input ">
<label class="cf-label" for="form2_checkbox01_0"> weiteres Medikament </label>
</div>
</div>
</div>
</div>
<div class="cf-control-group cf-hide cf-ignore" data-key="4" data-name="html_4" data-label="Medikament2" data-type="html" data-required-override="false">
<div class="cf-control-input">
<div>
<h3>Medikament 2</h3>
</div>
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="16" data-name="text_medikamentenname2" data-label="Name des Medikaments" data-type="text" data-required="" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textmedikamentenname2"> Name des Medikaments <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_medikamentenname2]" id="form2_textmedikamentenname2" aria-label="Name des Medikaments" aria-required="false" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="19" data-name="text_dosis2" data-label="Dosis" data-type="text" data-required="" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textdosis2"> Dosis <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_dosis2]" id="form2_textdosis2" aria-label="Dosis" aria-required="false" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="20" data-name="dropdown_verabreichung2" data-label="Verabreichungsform" data-type="dropdown" data-required="" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_dropdownverabreichung2"> Verabreichungsform <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<div class="cf-select cf-one-half">
<select name="cf[dropdown_verabreichung2]" id="form2_dropdownverabreichung2" aria-label="Verabreichungsform" aria-required="false" class="cf-input cf-one-half ">
<option value="Tablette" data-calc-value="Tablette"> Tablette </option>
<option value="Kapsel" data-calc-value="Kapsel"> Kapsel </option>
<option value="Sirup" data-calc-value="Sirup"> Sirup </option>
<option value="Spritzen" data-calc-value="Spritzen"> Spritzen </option>
<option value="Anderes" data-calc-value="Anderes"> Anderes </option>
</select>
</div>
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="22" data-name="text_anderes2" data-label="Anderes nämlich" data-type="text" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textanderes2"> Anderes nämlich </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_anderes2]" id="form2_textanderes2" aria-label="Anderes nämlich" class="cf-input " aria-required="false">
</div>
</div>
<div class="cf-control-group cf-hide cf-ignore" data-key="32" data-name="html_32" data-label="break" data-type="html" data-required-override="false">
<div class="cf-control-input">
<div> --</div>
</div>
</div>
<div class="cf-control-group cf-one-fourth cf-hide cf-ignore" data-key="25" data-name="text_anzahl2" data-label="Anzahl Packungen" data-type="text" data-required="" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textanzahl2"> Anzahl Packungen <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_anzahl2]" id="form2_textanzahl2" aria-label="Anzahl Packungen" aria-required="false" class="cf-input cf-one-half ">
</div>
</div>
<div class="cf-control-group cf-one-fourth cf-hide cf-ignore" data-key="23" data-name="text_pckgroesse2" data-label="Packungsgrösse" data-type="text" data-required="" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textpckgroesse2"> Packungsgrösse <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_pckgroesse2]" id="form2_textpckgroesse2" aria-label="Packungsgrösse" aria-required="false" class="cf-input cf-one-half ">
</div>
</div>
<div class="cf-control-group cf-hide cf-ignore" data-key="30" data-name="checkbox_02" data-type="checkbox" data-required="" data-required-override="false">
<div class="cf-control-input">
<div class="cf-list ">
<div class="cf-checkbox-group cf-checkbox-group-required ">
<input type="checkbox" name="cf[checkbox_02][]" id="form2_checkbox02_0" value="weiteres Medikament" data-calc-value="weiteres Medikament" aria-required="false" class="cf-input ">
<label class="cf-label" for="form2_checkbox02_0"> weiteres Medikament </label>
</div>
</div>
</div>
</div>
<div class="cf-control-group cf-hide cf-ignore" data-key="6" data-name="html_6" data-label="Medikament3" data-type="html" data-required-override="false">
<div class="cf-control-input">
<div>
<h3>Medikament 3</h3>
</div>
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="18" data-name="text_medikamentenname3" data-label="Name des Medikaments" data-type="text" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textmedikamentenname3"> Name des Medikaments </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_medikamentenname3]" id="form2_textmedikamentenname3" aria-label="Name des Medikaments" class="cf-input " aria-required="false">
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="17" data-name="text_dosis3" data-label="Dosis" data-type="text" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textdosis3"> Dosis </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_dosis3]" id="form2_textdosis3" aria-label="Dosis" class="cf-input " aria-required="false">
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="21" data-name="dropdown_verabreichung3" data-label="Verabreichungsform" data-type="dropdown" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_dropdownverabreichung3"> Verabreichungsform </label>
</div>
<div class="cf-control-input">
<div class="cf-select cf-one-half">
<select name="cf[dropdown_verabreichung3]" id="form2_dropdownverabreichung3" aria-label="Verabreichungsform" class="cf-input cf-one-half " aria-required="false">
<option value="Tablette" data-calc-value="Tablette"> Tablette </option>
<option value="Kapsel" data-calc-value="Kapsel"> Kapsel </option>
<option value="Sirup" data-calc-value="Sirup"> Sirup </option>
<option value="Spritzen" data-calc-value="Spritzen"> Spritzen </option>
<option value="Anderes" data-calc-value="Anderes"> Anderes </option>
</select>
</div>
</div>
</div>
<div class="cf-control-group cf-one-half cf-hide cf-ignore" data-key="27" data-name="text_anderes3" data-label="Anderes nämlich" data-type="text" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textanderes3"> Anderes nämlich </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_anderes3]" id="form2_textanderes3" aria-label="Anderes nämlich" class="cf-input " aria-required="false">
</div>
</div>
<div class="cf-control-group cf-hide cf-ignore" data-key="33" data-name="html_33" data-label="break" data-type="html" data-required-override="false">
<div class="cf-control-input">
<div> --</div>
</div>
</div>
<div class="cf-control-group cf-one-fourth cf-hide cf-ignore" data-key="26" data-name="text_anzahl3" data-label="Anzahl Packungen" data-type="text" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textanzahl3"> Anzahl Packungen </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_anzahl3]" id="form2_textanzahl3" aria-label="Anzahl Packungen" class="cf-input cf-one-half " aria-required="false">
</div>
</div>
<div class="cf-control-group cf-one-fourth cf-hide cf-ignore" data-key="24" data-name="text_pckgroesse3" data-label="Packungsgrösse" data-type="text" data-required-override="false">
<div class="cf-control-label">
<label class="cf-label" for="form2_textpckgroesse3"> Packungsgrösse </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_pckgroesse3]" id="form2_textpckgroesse3" aria-label="Packungsgrösse" class="cf-input cf-one-half " aria-required="false">
</div>
</div>
<div class="cf-control-group " data-key="31" data-name="textarea_bemerkungen" data-label="Bemerkungen" data-type="textarea">
<div class="cf-control-label">
<label class="cf-label" for="form2_textareabemerkungen"> Bemerkungen </label>
</div>
<div class="cf-control-input">
<textarea name="cf[textarea_bemerkungen]" id="form2_textareabemerkungen" aria-label="Bemerkungen" placeholder="" class="cf-input " rows="3"></textarea>
</div>
</div>
<div class="cf-control-group " data-key="2" data-name="submit_2" data-type="submit">
<div class="cf-control-input">
<div class="cf-text-center">
<button type="submit" class="cf-btn cf-one-third " "="">
<span class=" cf-btn-text">Senden</span>
<span class="cf-spinner-container">
<span class="cf-spinner">
<span class="bounce1" role="presentation"></span>
<span class="bounce2" role="presentation"></span>
<span class="bounce3" role="presentation"></span>
</span>
</span>
</button>
</div>
</div>
</div>
</div>
</div>
<input type="hidden" name="cf[form_id]" value="2">
<input type="hidden" name="72b75430ed77e1c31416b49eb3e27682" value="1">
<div class="cf-field-hp">
<input type="text" name="cf[hnpt_6747214393cf2]" autocomplete="off" class="cf-input" tabindex="-1">
</div>
</form>Name: cf5 — POST #
<form name="cf5" id="cf5" method="post" action="#">
<div class="cf-form-wrap cf-col-16 " style="background-color:none">
<div class="cf-response"></div>
<div class="cf-fields">
<div class="cf-control-group " data-key="5" data-name="html_5" data-label="HTML" data-type="html">
<div class="cf-control-input">
<div>
<h2>Überweisung Spezialsprechstunde</h2>
</div>
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="1" data-name="text_name" data-label="Name" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form5_textname"> Name <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_name]" id="form5_textname" aria-label="Name" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="37" data-name="text_versicherung" data-label="Versicherung" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form5_textversicherung"> Versicherung <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_versicherung]" id="form5_textversicherung" aria-label="Versicherung" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="7" data-name="text_vorname" data-label="Vorname" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form5_textvorname"> Vorname <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_vorname]" id="form5_textvorname" aria-label="Vorname" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="38" data-name="text_versicherungsnr" data-label="Versicherungs-Nr" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form5_textversicherungsnr"> Versicherungs-Nr <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_versicherungsnr]" id="form5_textversicherungsnr" aria-label="Versicherungs-Nr" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="8" data-name="datum_geburt" data-label="Geburtsdatum" data-type="datetime" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form5_datumgeburt"> Geburtsdatum <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[datum_geburt]" id="form5_datumgeburt" required="" aria-required="true" placeholder="-- Bitte Datum wählen --" autocomplete="off" class="cf-input flatpickr-input">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="39" data-name="text_arbeitgeber" data-label="Arbeitgeber" data-type="text">
<div class="cf-control-label">
<label class="cf-label" for="form5_textarbeitgeber"> Arbeitgeber </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_arbeitgeber]" id="form5_textarbeitgeber" aria-label="Arbeitgeber" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="34" data-name="text_strasse" data-label="Strasse/Haus-Nr." data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form5_textstrasse"> Strasse/Haus-Nr. <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_strasse]" id="form5_textstrasse" aria-label="Strasse/Haus-Nr." required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="40" data-name="text_telefong" data-label="Telefon/Mobile Arbeitgeber" data-type="text">
<div class="cf-control-label">
<label class="cf-label" for="form5_texttelefong"> Telefon/Mobile Arbeitgeber </label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_telefong]" id="form5_texttelefong" aria-label="Telefon/Mobile Arbeitgeber" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="35" data-name="text_plzort" data-label="PLZ/Ort" data-type="text" data-required="">
<div class="cf-control-label">
<label class="cf-label" for="form5_textplzort"> PLZ/Ort <span class="cf-required-label">*</span>
</label>
</div>
<div class="cf-control-input">
<input type="text" name="cf[text_plzort]" id="form5_textplzort" aria-label="PLZ/Ort" required="" aria-required="true" class="cf-input ">
</div>
</div>
<div class="cf-control-group cf-one-half" data-key="41" data-name="radio_krank-unfall" data-label="Krankheit / Unfall" data-type="radio" data-required="">
<div class="cf-control-label">
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<strong>Dr. med. Ulrich Beurer</strong> <br>Gynäkologie, Konsiliararzt SVAR
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<strong>Dr. med. Pascale Brei</strong> Handchirurgie
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<strong>Dr. med. Christian Eder</strong> Psychiatrie
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<strong>Dr. med. Jacqueline Fust</strong> Orthopädie und Traumatologie, spez. Fusschirurgie
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<strong>Dr. med. Christoph Hottkowitz</strong> Kardiologie
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<strong>Dr. med. Thomas Kempmann</strong> Gastroenterologie
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<strong>Dr. med. Daniel Meyer</strong> Urologie
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<strong>Dr. med. Carla Nauer</strong> Allgemeine Chirurgie, Viszeralchirugie und Proktologie, Konsiliarärztin SVAR
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<strong>Dr. med. Susanne Schwarz</strong> Schmerzmedizin
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<strong>Dr. med. Tanja Staub</strong> Nephrologie, Konsiliarärztin SVAR
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<strong>Dipl. med. Simon Peter Wespi</strong> Pneumologie
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Dr. med. Ulrich Beurer
Gynäkologie, Konsiliararzt SVAR
Dr. med. Pascale Brei Handchirurgie
Dr. med. Christian Eder Psychiatrie
Dr. med. Jacqueline Fust Orthopädie und Traumatologie, spez. Fusschirurgie
Dr. med. Christoph Hottkowitz Kardiologie
Dr. med. Thomas Kempmann Gastroenterologie
Dr. med. Daniel Meyer Urologie
Dr. med. Carla Nauer Allgemeine Chirurgie, Viszeralchirugie und Proktologie,
Konsiliarärztin SVAR
Dr. med. Susanne Schwarz Schmerzmedizin
Dr. med. Tanja Staub Nephrologie, Konsiliarärztin SVAR
Dipl. med. Simon Peter Wespi Pneumologie
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