{"id":2620,"date":"2023-03-08T14:14:40","date_gmt":"2023-03-08T13:14:40","guid":{"rendered":"https:\/\/huisartsenpostgorinchem.nl\/?page_id=2620"},"modified":"2024-04-30T11:52:46","modified_gmt":"2024-04-30T09:52:46","slug":"formularz-reklamacyjny","status":"publish","type":"page","link":"https:\/\/huisartsenspoedpostgorinchem.nl\/pl\/formularz-skarga-lub-komplement\/formularz-reklamacyjny\/","title":{"rendered":"Formularz reklamacyjny"},"content":{"rendered":"\n\n\n<p>\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework complaint-form_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Formularz skarg<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; oznacza pola wymagane<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1' class='complaint-form' action='\/pl\/wp-json\/wp\/v2\/pages\/2620' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><div id=\"field_1_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dane zg\u0142aszaj\u0105cego<\/h3><\/div><fieldset id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >P\u0142e\u0107<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_4'>\n\t\t\t<div class='gchoice gchoice_1_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='M\u0119ski'  id='choice_1_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_0' id='label_1_4_0' class='gform-field-label gform-field-label--type-inline'>M\u0119ski<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='\u017be\u0144ski'  id='choice_1_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_4_1' id='label_1_4_1' class='gform-field-label gform-field-label--type-inline'>\u017be\u0144ski<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Inicja\u0142y<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Przyimek<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Nazwisko<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Adres e-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_12' id='input_1_12' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Telefon<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_1_13' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Data urodzenia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_1_15' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/rrrr' aria-describedby=\"input_1_15_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_15_date_format' class='screen-reader-text'>DD uko\u015bnik MM uko\u015bnik RRRR<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_15' class='gform_hidden' value='https:\/\/huisartsenspoedpostgorinchem.nl\/pl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Adres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Kod pocztowy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>Miejsce<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_1_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Kraj<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Skarga w imieniu kogo\u015b innego<\/h3><\/div><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sk\u0142adasz skarg\u0119 w imieniu kogo\u015b innego?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Nie'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>Nie<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Tak'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>Tak<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_62\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full complaint-form__sub-form gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Jaka jest pa\u0144stwa relacja do pacjenta?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_1_24' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Rodzic lub opiekun' >Rodzic lub opiekun<\/option><option value='Dziecko' >Dziecko<\/option><option value='Rodzina' >Rodzina<\/option><option value='Inne' >Inne<\/option><\/select><\/div><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full complaint-form__cta gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><span class=\"bold\">Prosz\u0119 wype\u0142ni\u0107 poni\u017cej dane pacjenta<\/span><\/div><fieldset id=\"field_1_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >P\u0142e\u0107<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_25'>\n\t\t\t<div class='gchoice gchoice_1_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='M\u0119ski'  id='choice_1_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>M\u0119ski<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='\u017be\u0144ski'  id='choice_1_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>\u017be\u0144ski<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Inicja\u0142y<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Przyimek<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Nazwisko<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Adres e-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_1_33' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>Telefon<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Data urodzenia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_30' id='input_1_30' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/rrrr' aria-describedby=\"input_1_30_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_30_date_format' class='screen-reader-text'>DD uko\u015bnik MM uko\u015bnik RRRR<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_30' class='gform_hidden' value='https:\/\/huisartsenspoedpostgorinchem.nl\/pl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_34'>Ulica + numer domu<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_1_34' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Kod pocztowy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Miejsce<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_37'>Kraj<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Opis skargi<\/h3><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Data zdarzenia<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_38' id='input_1_38' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/rrrr' aria-describedby=\"input_1_38_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_38_date_format' class='screen-reader-text'>DD uko\u015bnik MM uko\u015bnik RRRR<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_38' class='gform_hidden' value='https:\/\/huisartsenspoedpostgorinchem.nl\/pl\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Opis skargi \/ problemu<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_1_39' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>Pa\u0144stwa zg\u0142oszenie dotyczy<\/label><div class='ginput_container ginput_container_select'><select name='input_40' id='input_1_40' class='large gfield_select'     aria-invalid=\"false\" ><option value='organizacji' >organizacji<\/option><option value='tria\u017cystki, telefonistki, asystentki' >tria\u017cystki, telefonistki, asystentki<\/option><option value='kierowcy' >kierowcy<\/option><option value='lekarza rodzinnej' >lekarza rodzinnej<\/option><\/select><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Jaka jest pa\u0144stwa zdaniem przyczyna?<\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_1_41' class='large gfield_select'     aria-invalid=\"false\" ><option value='czasy oczekiwania' >czasy oczekiwania<\/option><option value='nieprawid\u0142owa ocena pilno\u015bci mojego pytania' >nieprawid\u0142owa ocena pilno\u015bci mojego pytania<\/option><option value='niew\u0142a\u015bciwe leczenie' >niew\u0142a\u015bciwe leczenie<\/option><option value='niewykwalifikowany pracownik medyczny' >niewykwalifikowany pracownik medyczny<\/option><option value='traktowanie' >traktowanie<\/option><option value='inaczej, tj.' >inaczej, tj.<\/option><\/select><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>Opisz przyczyn\u0119 skargi \/ problemu<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_1_42' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Czy mo\u017cna by\u0142o unikn\u0105\u0107 zdarzenia?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_43'>\n\t\t\t<div class='gchoice gchoice_1_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Nie'  id='choice_1_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_0' id='label_1_43_0' class='gform-field-label gform-field-label--type-inline'>Nie<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Tak'  id='choice_1_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Tak<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_54\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>Czy maj\u0105 pa\u0144stwo zalecenia, jak unikn\u0105\u0107 takiego zdarzenia w przysz\u0142o\u015bci?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_1_44' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Czy pacjent lub przedstawiciel udziela zgody na wgl\u0105d do dokumentacji?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_68'>Wgl\u0105d jest konieczny, aby pracownik ds. skarg m\u00f3g\u0142 dok\u0142adnie rozpatrzy\u0107 pa\u0144stwa skarg\u0119<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_68'>\n\t\t\t<div class='gchoice gchoice_1_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Tak'  id='choice_1_68_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_68\"   \/>\n\t\t\t\t\t<label for='choice_1_68_0' id='label_1_68_0' class='gform-field-label gform-field-label--type-inline'>Tak<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Nie'  id='choice_1_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>Nie<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_61\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_61'>CAPTCHA<\/label><div id='input_1_61' class='ginput_container ginput_recaptcha' data-sitekey='6LdF7OEkAAAAAB_bQLYsQWhGj41-rhXFMWfqN4Hd'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Wys\u0142a\u0107'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' 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