{"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":"2025-08-17T21:00:05","modified_gmt":"2025-08-17T21:00:05","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=\"heroic choir\" 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 or print out the attached PDF, fill it out and send it to us.<\/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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:4.8%;--awb-spacing-left-medium:4.8%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:4.8%;--awb-spacing-left-medium:4.8%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:5.76%;--awb-spacing-left-medium:5.76%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:3.84%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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:0;--awb-flex-shrink-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-flex-grow-small:0;--awb-flex-shrink-small:0;--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-69f29f4f169b9\" 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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