{"id":10094,"date":"2025-05-20T14:52:15","date_gmt":"2025-05-20T14:52:15","guid":{"rendered":"https:\/\/www.swiss-heart-clinic.com\/registration-form-for-doctors\/"},"modified":"2026-07-24T13:26:29","modified_gmt":"2026-07-24T13:26:29","slug":"registration-form-for-doctors","status":"publish","type":"page","link":"https:\/\/www.swiss-heart-clinic.com\/en\/registration-form-for-doctors\/","title":{"rendered":"Referral form for doctors"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-small-visibility containergradient1\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top-small:0px;--awb-padding-right-small:30px;--awb-padding-bottom-small:0px;--awb-padding-left-small:30px;--awb-min-height:10px;--awb-background-color:var(--awb-color6);--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><\/div><\/div><div id=\"heroanchor\" class=\"fusion-container-anchor\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-small-visibility\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:30px;--awb-padding-right:18%;--awb-padding-bottom:0px;--awb-padding-left:12%;--awb-margin-top:0px;--awb-margin-bottom:0px;--awb-flex-wrap:wrap;\" ><div class=\"awb-background-pattern\" style=\"background-image:  url(data:image\/svg+xml;utf8,%3Csvg%20width%3D%22160%22%20height%3D%22120%22%20fill%3D%22none%22%20xmlns%3D%22http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg%22%3E%3Cg%20clip-path%3D%22url%28%23prefix__clip0_43_381%29%22%20stroke%3D%22rgba%28146%2C42%2C46%2C1%29%22%20stroke-width%3D%222%22%3E%3Cpath%20d%3D%22M-66.839%2019.027C-44.46%2018.538-22.38%207.377%200%207.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.527M-66.839%2049.028C-44.46%2048.537-22.38%2037.377%200%2037.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.528M-66.839%2079.028C-44.46%2078.537-22.38%2067.377%200%2067.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.528M-66.839%20109.027C-44.46%20108.537-22.38%2097.377%200%2097.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.527%22%2F%3E%3C%2Fg%3E%3Cdefs%3E%3CclipPath%20id%3D%22prefix__clip0_43_381%22%3E%3Cpath%20fill%3D%22%23fff%22%20d%3D%22M0%200h160v120H0z%22%2F%3E%3C%2FclipPath%3E%3C%2Fdefs%3E%3C%2Fsvg%3E);opacity: 0.12 ;background-size:6%;mix-blend-mode:normal;\"><\/div><div class=\"awb-background-mask\" style=\"background-image:  url(data:image\/svg+xml;utf8,%3Csvg%20width%3D%221920%22%20height%3D%22954%22%20fill%3D%22none%22%20xmlns%3D%22http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg%22%3E%3Cg%20clip-path%3D%22url%28%23prefix__clip0_58_745%29%22%20fill%3D%22rgba%28255%2C255%2C255%2C1%29%22%3E%3Cpath%20d%3D%22M250.018-408.977c69.019-18.494%20142.66%201.238%20193.185%2051.763L718.31-82.107c50.525%2050.525%2070.258%20124.167%2051.764%20193.185L669.378%20486.881c-18.493%2069.019-72.403%20122.928-141.421%20141.422L152.154%20728.999c-69.019%2018.493-142.66-1.239-193.186-51.764l-275.106-275.107c-50.525-50.525-70.258-124.167-51.764-193.185l100.696-375.803c18.493-69.018%2072.403-122.928%20141.421-141.421l375.803-100.696zM1646.73%201264.15c33.13%208.88%2068.48-.59%2092.73-24.84l147.89-147.89a96.031%2096.031%200%200024.85-92.732l-54.13-202.022a96.012%2096.012%200%2000-67.89-67.882l-202.02-54.132c-33.13-8.877-68.47.595-92.73%2024.847l-147.89%20147.89a95.994%2095.994%200%2000-24.84%2092.729l54.13%20202.022a95.967%2095.967%200%200067.88%2067.88l202.02%2054.13zM1572.48%20252.659a23.996%2023.996%200%200023.18%206.211l50.5-13.533a23.97%2023.97%200%200016.97-16.97l13.54-50.506a24.004%2024.004%200%2000-6.21-23.182l-36.98-36.973a23.993%2023.993%200%2000-23.18-6.211l-50.5%2013.533a24%2024%200%2000-16.98%2016.97l-13.53%2050.506a24.004%2024.004%200%20006.21%2023.182l36.98%2036.973z%22%2F%3E%3C%2Fg%3E%3Cdefs%3E%3CclipPath%20id%3D%22prefix__clip0_58_745%22%3E%3Cpath%20fill%3D%22%23fff%22%20d%3D%22M0%200h1920v954H0z%22%2F%3E%3C%2FclipPath%3E%3C%2Fdefs%3E%3C%2Fsvg%3E);opacity: 1 ;transform: scale(1, -1);mix-blend-mode:normal;\"><\/div><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column fusion-animated\" style=\"--awb-bg-color:rgba(255,255,255,0);--awb-bg-color-hover:rgba(255,255,255,0);--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:4%;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:3%;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\" data-animationType=\"fadeIn\" data-animationDuration=\"0.3\" data-animationOffset=\"top-into-view\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"--awb-text-color:var(--awb-color6);--awb-margin-bottom:0px;--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:10px;--awb-margin-left-small:0px;--awb-font-size:25px;\"><h3 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;letter-spacing:1px;font-size:1em;--fontSize:25;line-height:1.3;\">ONLINE FORM OR PDF<\/h3><\/div><div class=\"fusion-title title fusion-title-2 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-margin-right:20px;--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:10px;--awb-margin-left-small:0px;--awb-font-size:40px;\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:40;line-height:1.3;\">Patient referral<\/h1><\/div><div class=\"fusion-text fusion-text-1\" style=\"--awb-font-size:20px;--awb-line-height:1.6em;--awb-letter-spacing:0.8px;--awb-margin-right:50px;\"><p>To register patients at the Hirslanden Heart Clinic, you can fill out our online registration form electronically and submit it directly, or print out the attached PDF, fill it out, and email it to us at <a href=\"mailto:herzklinik.hirslanden@hirslanden.ch\">herzklinik.hirslanden@hirslanden.ch<\/a>.<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 fusion-flex-container has-pattern-background has-mask-background hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-medium-visibility fusion-no-large-visibility containergradient1\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top-small:15px;--awb-padding-right-small:30px;--awb-padding-bottom-small:15px;--awb-padding-left-small:30px;--awb-min-height:10px;--awb-min-height-small:20px;--awb-background-color:var(--awb-color6);--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><\/div><\/div><div id=\"anchor team\" class=\"fusion-container-anchor\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-4 fusion-flex-container has-pattern-background has-mask-background hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-no-medium-visibility fusion-no-large-visibility\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:30px;--awb-padding-right:5%;--awb-padding-bottom:0px;--awb-padding-left:5%;--awb-padding-right-small:20px;--awb-padding-left-small:20px;--awb-margin-top:0px;--awb-margin-bottom:0px;--awb-flex-wrap:wrap;\" ><div class=\"awb-background-pattern\" style=\"background-image:  url(data:image\/svg+xml;utf8,%3Csvg%20width%3D%22160%22%20height%3D%22120%22%20fill%3D%22none%22%20xmlns%3D%22http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg%22%3E%3Cg%20clip-path%3D%22url%28%23prefix__clip0_43_381%29%22%20stroke%3D%22rgba%28146%2C42%2C46%2C1%29%22%20stroke-width%3D%222%22%3E%3Cpath%20d%3D%22M-66.839%2019.027C-44.46%2018.538-22.38%207.377%200%207.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.527M-66.839%2049.028C-44.46%2048.537-22.38%2037.377%200%2037.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.528M-66.839%2079.028C-44.46%2078.537-22.38%2067.377%200%2067.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.528M-66.839%20109.027C-44.46%20108.537-22.38%2097.377%200%2097.5c22.383.123%2057.617%2015%2080%2015%2022.383%200%2057.617-14.877%2080-15%2022.381-.123%2044.461%2011.037%2066.839%2011.527%22%2F%3E%3C%2Fg%3E%3Cdefs%3E%3CclipPath%20id%3D%22prefix__clip0_43_381%22%3E%3Cpath%20fill%3D%22%23fff%22%20d%3D%22M0%200h160v120H0z%22%2F%3E%3C%2FclipPath%3E%3C%2Fdefs%3E%3C%2Fsvg%3E);opacity: 0.05 ;background-size:15%;mix-blend-mode:normal;\"><\/div><div class=\"awb-background-mask\" style=\"background-image:  url(data:image\/svg+xml;utf8,%3Csvg%20width%3D%221920%22%20height%3D%22954%22%20fill%3D%22none%22%20xmlns%3D%22http%3A%2F%2Fwww.w3.org%2F2000%2Fsvg%22%3E%3Cg%20clip-path%3D%22url%28%23prefix__clip0_58_745%29%22%20fill%3D%22rgba%28255%2C255%2C255%2C1%29%22%3E%3Cpath%20d%3D%22M250.018-408.977c69.019-18.494%20142.66%201.238%20193.185%2051.763L718.31-82.107c50.525%2050.525%2070.258%20124.167%2051.764%20193.185L669.378%20486.881c-18.493%2069.019-72.403%20122.928-141.421%20141.422L152.154%20728.999c-69.019%2018.493-142.66-1.239-193.186-51.764l-275.106-275.107c-50.525-50.525-70.258-124.167-51.764-193.185l100.696-375.803c18.493-69.018%2072.403-122.928%20141.421-141.421l375.803-100.696zM1646.73%201264.15c33.13%208.88%2068.48-.59%2092.73-24.84l147.89-147.89a96.031%2096.031%200%200024.85-92.732l-54.13-202.022a96.012%2096.012%200%2000-67.89-67.882l-202.02-54.132c-33.13-8.877-68.47.595-92.73%2024.847l-147.89%20147.89a95.994%2095.994%200%2000-24.84%2092.729l54.13%20202.022a95.967%2095.967%200%200067.88%2067.88l202.02%2054.13zM1572.48%20252.659a23.996%2023.996%200%200023.18%206.211l50.5-13.533a23.97%2023.97%200%200016.97-16.97l13.54-50.506a24.004%2024.004%200%2000-6.21-23.182l-36.98-36.973a23.993%2023.993%200%2000-23.18-6.211l-50.5%2013.533a24%2024%200%2000-16.98%2016.97l-13.53%2050.506a24.004%2024.004%200%20006.21%2023.182l36.98%2036.973z%22%2F%3E%3C%2Fg%3E%3Cdefs%3E%3CclipPath%20id%3D%22prefix__clip0_58_745%22%3E%3Cpath%20fill%3D%22%23fff%22%20d%3D%22M0%200h1920v954H0z%22%2F%3E%3C%2FclipPath%3E%3C%2Fdefs%3E%3C%2Fsvg%3E);opacity: 1 ;transform: scale(1, -1);mix-blend-mode:normal;\"><\/div><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column fusion-animated\" style=\"--awb-bg-color:rgba(255,255,255,0);--awb-bg-color-hover:rgba(255,255,255,0);--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:20px;--awb-margin-bottom-large:20px;--awb-spacing-left-large:20px;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:20px;--awb-spacing-left-medium:20px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:20px;--awb-spacing-left-small:20px;\" data-animationType=\"fadeIn\" data-animationDuration=\"0.3\" data-animationOffset=\"top-into-view\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-3 fusion-sep-none fusion-title-text fusion-title-size-three\" style=\"--awb-text-color:var(--awb-color6);--awb-margin-top:30px;--awb-margin-bottom:0px;--awb-margin-top-small:30px;--awb-margin-right-small:0px;--awb-margin-bottom-small:0px;--awb-margin-left-small:0px;--awb-font-size:18px;\"><h3 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:18;--minFontSize:18;line-height:1.3;\">ONLINE FORM OR PDF<\/h3><\/div><div class=\"fusion-title title fusion-title-4 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-margin-top:0px;--awb-margin-bottom:25px;--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;--awb-font-size:34px;\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:34;line-height:1.3;\">Patient referral<\/h1><\/div><div class=\"fusion-text fusion-text-2\" style=\"--awb-font-size:16px;--awb-line-height:1.6em;--awb-letter-spacing:0.8px;\"><p>To refer a patient to the Heart Clinic Hirslanden Zurich, please fill in our online referral form or print the attached PDF, fill it in and send it to us by email.<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-5 fusion-flex-container has-pattern-background has-mask-background hundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:30px;--awb-padding-right:12%;--awb-padding-left:12%;--awb-margin-bottom:40px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:calc( 100% + 70px ) !important;max-width:calc( 100% + 70px ) !important;margin-left: calc(-70px \/ 2 );margin-right: calc(-70px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:35px;--awb-margin-bottom-large:20px;--awb-spacing-left-large:35px;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:35px;--awb-spacing-left-medium:35px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:35px;--awb-spacing-left-small:35px;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-10212 has-icon-alignment\" style=\"--awb-tooltip-text-color:var(--awb-color1);--awb-tooltip-background-color:var(--awb-color7);--awb-field-margin-bottom:0px;--awb-form-input-height:50px;--awb-form-bg-color:#f7f7f7;--awb-form-placeholder-color:hsla(var(--awb-color8-h),var(--awb-color8-s),var(--awb-color8-l),calc(var(--awb-color8-a) - 20%));--awb-form-text-color:var(--awb-color8);--awb-form-label-color:var(--awb-color8);--awb-form-border-width-top:0px;--awb-form-border-width-bottom:2px;--awb-form-border-width-right:2px;--awb-form-border-width-left:0px;--awb-form-border-color:var(--awb-color6);--awb-form-focus-border-color:var(--awb-color8);--awb-form-focus-border-hover-color:hsla(var(--awb-color8-h),var(--awb-color8-s),var(--awb-color8-l),calc(var(--awb-color8-a) - 50%));--awb-form-border-radius:3px;--awb-icon-alignment-top:0px;--awb-icon-alignment-bottom:2px;--awb-icon-alignment-font-size:1em;\" data-form-id=\"10212\" data-config=\"{&quot;form_id&quot;:10212,&quot;form_post_id&quot;:10212,&quot;post_id&quot;:10094,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;redirect_timeout&quot;:&quot;0&quot;,&quot;field_labels&quot;:{&quot;gewunschte_einzeluntersuchung&quot;:&quot;&quot;,&quot;gewunschte_ambulante_sprechstunde&quot;:&quot;&quot;,&quot;anrede&quot;:&quot;&quot;,&quot;name&quot;:&quot;&quot;,&quot;vorname&quot;:&quot;&quot;,&quot;geburtsdatum&quot;:&quot;&quot;,&quot;postleitzahl&quot;:&quot;&quot;,&quot;adresse&quot;:&quot;&quot;,&quot;krankenkasse&quot;:&quot;&quot;,&quot;krankenkassen_typ&quot;:&quot;&quot;,&quot;selbstzahler&quot;:&quot;&quot;,&quot;klinische_diagnose&quot;:&quot;&quot;,&quot;fragestellung&quot;:&quot;&quot;,&quot;zuweisender_arzt&quot;:&quot;&quot;,&quot;direktetelefonnummer&quot;:&quot;&quot;,&quot;emailadresse&quot;:&quot;&quot;,&quot;datum_anfrage&quot;:&quot;&quot;,&quot;consent&quot;:&quot;&quot;},&quot;field_logics&quot;:{&quot;gewunschte_einzeluntersuchung&quot;:&quot;&quot;,&quot;gewunschte_ambulante_sprechstunde&quot;:&quot;&quot;,&quot;anrede&quot;:&quot;&quot;,&quot;name&quot;:&quot;&quot;,&quot;vorname&quot;:&quot;&quot;,&quot;geburtsdatum&quot;:&quot;&quot;,&quot;postleitzahl&quot;:&quot;&quot;,&quot;adresse&quot;:&quot;&quot;,&quot;krankenkasse&quot;:&quot;&quot;,&quot;krankenkassen_typ&quot;:&quot;&quot;,&quot;selbstzahler&quot;:&quot;&quot;,&quot;klinische_diagnose&quot;:&quot;&quot;,&quot;fragestellung&quot;:&quot;&quot;,&quot;zuweisender_arzt&quot;:&quot;&quot;,&quot;direktetelefonnummer&quot;:&quot;&quot;,&quot;emailadresse&quot;:&quot;&quot;,&quot;datum_anfrage&quot;:&quot;&quot;,&quot;consent&quot;:&quot;&quot;,&quot;submit_1&quot;:&quot;&quot;,&quot;notice_1&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;gewunschte_einzeluntersuchung&quot;:&quot;checkbox&quot;,&quot;gewunschte_ambulante_sprechstunde&quot;:&quot;checkbox&quot;,&quot;anrede&quot;:&quot;select&quot;,&quot;name&quot;:&quot;text&quot;,&quot;vorname&quot;:&quot;text&quot;,&quot;geburtsdatum&quot;:&quot;date&quot;,&quot;postleitzahl&quot;:&quot;text&quot;,&quot;adresse&quot;:&quot;text&quot;,&quot;krankenkasse&quot;:&quot;text&quot;,&quot;krankenkassen_typ&quot;:&quot;select&quot;,&quot;selbstzahler&quot;:&quot;select&quot;,&quot;klinische_diagnose&quot;:&quot;text&quot;,&quot;fragestellung&quot;:&quot;text&quot;,&quot;zuweisender_arzt&quot;:&quot;text&quot;,&quot;direktetelefonnummer&quot;:&quot;phone_number&quot;,&quot;emailadresse&quot;:&quot;email&quot;,&quot;datum_anfrage&quot;:&quot;date&quot;,&quot;hypot_field&quot;:&quot;honeypot&quot;,&quot;consent&quot;:&quot;consent&quot;,&quot;submit_1&quot;:&quot;submit&quot;,&quot;notice_1&quot;:&quot;notice&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;,&quot;form_views&quot;:&quot;ajax&quot;,&quot;form_views_counting&quot;:&quot;all&quot;}\"><form action=\"https:\/\/www.swiss-heart-clinic.com\/en\/registration-form-for-doctors\/\" method=\"post\" class=\"fusion-form fusion-form-10212\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-5-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-right:0px;--awb-padding-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_2_5 2_5 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:40%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:4.8%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:4.8%;--awb-width-medium:40%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:4.8%;--awb-spacing-left-medium:4.8%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-5 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:10px;--awb-margin-left-small:0px;--awb-font-size:22px;\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:22;--minFontSize:22;line-height:1.3;\">Requested examination<\/h1><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><fieldset data-awb-fieldset-min-required=\"0\" data-awb-fieldset-max-required=\"0\" data-awb-fieldset-error=\"\"><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-0\" type=\"checkbox\" value=\"Resting ECG\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-0\">Resting ECG<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-1\" type=\"checkbox\" value=\"Long-term ECG (24 hours)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-1\">Long-term ECG (24 hours)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-2\" type=\"checkbox\" value=\"Long-term ECG (48 hours)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-2\">Long-term ECG (48 hours)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-3\" type=\"checkbox\" value=\"Long-term ECG (7 days)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-3\">Long-term ECG (7 days)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-4\" type=\"checkbox\" value=\"Exercise ECG (bicycle)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-4\">Exercise ECG (bicycle)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-5\" type=\"checkbox\" value=\"Spiroergometry (bicycle)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-5\">Spiroergometry (bicycle)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-6\" type=\"checkbox\" value=\"Echocardiography (TTE)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-6\">Echocardiography (TTE)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-7\" type=\"checkbox\" value=\"Echocardiography (TEE)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-7\">Echocardiography (TEE)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-8\" type=\"checkbox\" value=\"Echocardiography (stress echo)\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-8\">Echocardiography (stress echo)<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-9\" type=\"checkbox\" value=\"24-hour blood pressure measurement\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-9\">24-hour blood pressure measurement<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-10\" type=\"checkbox\" value=\"Pacemaker\/ICD control\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-10\">Pacemaker\/ICD control<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-11\" type=\"checkbox\" value=\"Coronary CT\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-11\">Coronary CT<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-12\" type=\"checkbox\" value=\"Heart MRI\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-12\">Heart MRI<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-13\" type=\"checkbox\" value=\"Coronary angiography\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-13\">Coronary angiography<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_einzeluntersuchung-1-14\" type=\"checkbox\" value=\"Right heart catheter\" name=\"gewunschte_einzeluntersuchung[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_einzeluntersuchung-1-14\">Right heart catheter<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_2_5 2_5 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:40%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:4.8%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:4.8%;--awb-width-medium:40%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:4.8%;--awb-spacing-left-medium:4.8%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-6 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:10px;--awb-margin-left-small:0px;--awb-font-size:22px;\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:22;--minFontSize:22;line-height:1.3;\">Desired specialized outpatient clinic<\/h1><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><fieldset data-awb-fieldset-min-required=\"0\" data-awb-fieldset-max-required=\"0\" data-awb-fieldset-error=\"\"><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-0\" type=\"checkbox\" value=\"General cardiology\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-0\">General cardiology<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-1\" type=\"checkbox\" value=\"Heart failure\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-1\">Heart failure<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-2\" type=\"checkbox\" value=\"Rhythmogenic heart disease\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-2\">Rhythmogenic heart disease<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-3\" type=\"checkbox\" value=\"Valvular heart disease\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-3\">Valvular heart disease<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-4\" type=\"checkbox\" value=\"Coronary heart disease\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-4\">Coronary heart disease<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-5\" type=\"checkbox\" value=\"Hypertension\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-5\">Hypertension<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-6\" type=\"checkbox\" value=\"Lipids\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-6\">Lipids<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-gewunschte_ambulante_sprechstunde-2-7\" type=\"checkbox\" value=\"Diving\" name=\"gewunschte_ambulante_sprechstunde[]\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"checkbox-gewunschte_ambulante_sprechstunde-2-7\">Diving<\/label><\/div><\/fieldset><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-7 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-margin-bottom:0px;--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:10px;--awb-margin-left-small:0px;--awb-font-size:24px;\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:24;line-height:1.3;\">Patient information<\/h1><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"anrede\" name=\"anrede\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Title<\/option><option value=\"Mr.\" >Mr.<\/option><option value=\"Mrs.\" >Mrs.<\/option><option value=\"Other\" >Other<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\"  data-invalid-notice=\"Die Eingabe ist ung\u00fcltig.\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"name\" id=\"name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Family name *\" data-holds-private-data=\"false\" minlength=\"2\" maxlength=\"50\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\"  data-invalid-notice=\"Die Eingabe ist ung\u00fcltig.\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"vorname\" id=\"vorname\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"First name *\" data-holds-private-data=\"false\" minlength=\"2\" maxlength=\"50\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input autocomplete=\"off\" type=\"date\" data-first-day=\"1\"  data-format=\"d.m.Y\" tabindex=\"\" id=\"geburtsdatum\" name=\"geburtsdatum\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Date of birth *\"autocomplete=\"no\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\"  pattern=\"[0-9]+\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"postleitzahl\" id=\"postleitzahl\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Zip code *\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"adresse\" id=\"adresse\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address *\" data-holds-private-data=\"false\" minlength=\"2\" maxlength=\"120\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\" name=\"krankenkasse\" id=\"krankenkasse\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Health insurance \" data-holds-private-data=\"false\" minlength=\"2\" maxlength=\"38\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"krankenkassen_typ\" name=\"krankenkassen_typ\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Health insurance type<\/option><option value=\"General\" >General<\/option><option value=\"Semi-private\" >Semi-private<\/option><option value=\"Private\" >Private<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:33.333333333333%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><div class=\"fusion-select-wrapper\"><select autocomplete=\"off\" tabindex=\"\" id=\"selbstzahler\" name=\"selbstzahler\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Self-payer<\/option><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\"  data-invalid-notice=\"Die Eingabe ist ung\u00fcltig.\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"klinische_diagnose\" id=\"klinische_diagnose\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Suspected diagnosis *\" data-holds-private-data=\"false\" minlength=\"0\" maxlength=\"120\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\"  data-invalid-notice=\"Die Eingabe ist ung\u00fcltig.\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"fragestellung\" id=\"fragestellung\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Question *\" data-holds-private-data=\"false\" minlength=\"0\" maxlength=\"120\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-8 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-margin-top:20px;--awb-margin-bottom:10px;--awb-margin-top-small:10px;--awb-margin-right-small:0px;--awb-margin-bottom-small:10px;--awb-margin-left-small:0px;--awb-font-size:24px;\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:24;line-height:1.3;\">Details of the referring doctor<\/h1><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.84%;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"text\" autocomplete=\"off\"  data-invalid-notice=\"Die Eingabe ist ung\u00fcltig.\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"zuweisender_arzt\" id=\"zuweisender_arzt\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Referring doctor *\" data-holds-private-data=\"false\" minlength=\"2\" maxlength=\"120\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.84%;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"tel\" autocomplete=\"off\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"direktetelefonnummer\" id=\"direktetelefonnummer\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Direct telephone number *\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.84%;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"email\" autocomplete=\"off\"  data-empty-notice=\"Bitte f\u00fcllen Sie dieses Feld aus.\" name=\"emailadresse\" id=\"emailadresse\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"E-mail address *\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-20 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.84%;--awb-width-medium:50%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input autocomplete=\"off\" type=\"date\" data-first-day=\"1\"  data-format=\"d.m.Y\" tabindex=\"\" id=\"datum_anfrage\" name=\"datum_anfrage\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"Date \"autocomplete=\"no\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-21 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-flex-grow:0;--awb-flex-shrink:0;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-flex-grow-medium:;--awb-flex-shrink-medium:;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:;--awb-flex-shrink-small:;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-honeypot-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><input type=\"hidden\" tabindex=\"-1\" name=\"hypot_field\" class=\"fusion-form-input\" autocomplete=\"hypot-6a7d84035b766\" aria-hidden=\"true\" data-fusion-is-honeypot=\"true\"><\/div><div class=\"fusion-form-field fusion-form-consent-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><div class=\"fusion-form-checkbox option-inline\"><input tabindex=\"\" id=\"consent\" type=\"checkbox\" value=\"1\" name=\"consent\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\"\/><label for=\"consent\">By submitting this form, you consent to the processing of your data in accordance with our <a href=\"https:\/\/www.swiss-heart-clinic.com\/en\/privacy-policy\/\">privacy policy.<\/a><\/label><\/div><\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"10212\"><div ><button type=\"submit\" class=\"fusion-button button-flat button-xlarge button-custom fusion-button-default button-1 fusion-button-span-yes  button-default form-form-submit\" style=\"--button_accent_color:var(--awb-color1);--button_accent_hover_color:var(--awb-color1);--button_border_hover_color:var(--awb-color8);--button_border_width-top:0px;--button_border_width-right:0px;--button_border_width-bottom:0px;--button_border_width-left:0px;--button_gradient_top_color:var(--awb-color6);--button_gradient_bottom_color:var(--awb-color6);--button_gradient_top_color_hover:var(--awb-color8);--button_gradient_bottom_color_hover:var(--awb-color8);\" data-form-number=\"10212\" tabindex=\"\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Send registration<\/span><\/button><\/div><\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat button-xlarge button-custom fusion-button-default button-2 fusion-button-span-yes fusion-button-default-type\" style=\"--awb-margin-top:30px;--button_accent_color:var(--awb-color6);--button_accent_hover_color:var(--awb-color8);--button_border_hover_color:var(--awb-color8);--button_border_width-top:2px;--button_border_width-right:2px;--button_border_width-bottom:2px;--button_border_width-left:2px;--button-border-radius-top-left:2px;--button-border-radius-top-right:2px;--button-border-radius-bottom-right:2px;--button-border-radius-bottom-left:2px;--button_gradient_top_color:rgba(0,0,0,0);--button_gradient_bottom_color:rgba(0,0,0,0);--button_gradient_top_color_hover:rgba(0,0,0,0);--button_gradient_bottom_color_hover:rgba(0,0,0,0);\" target=\"_blank\" rel=\"noopener noreferrer\" href=\"https:\/\/www.swiss-heart-clinic.com\/wp-content\/uploads\/2025\/05\/Herzklinik-Hirslanden-Patientenanmeldung-PDF.pdf\"><i class=\"fa-file-pdf fas awb-button__icon awb-button__icon--default button-icon-left\" aria-hidden=\"true\"><\/i><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Download PDF for registration<\/span><\/a><\/div><div class=\"form-submission-notices data-notice_1\" id=\"fusion-notices-1\" data-instance=\"1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Your message has been sent successfully. 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