{"id":1928,"date":"2025-02-25T14:30:27","date_gmt":"2025-02-25T14:30:27","guid":{"rendered":"https:\/\/cad.healthcare\/kontakt\/"},"modified":"2025-03-31T14:47:44","modified_gmt":"2025-03-31T14:47:44","slug":"kontakt","status":"publish","type":"page","link":"https:\/\/cad.healthcare\/de\/kontakt\/","title":{"rendered":"Kontakt"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8220;1&#8243; admin_label=&#8220;Sezione&#8220; module_id=&#8220;Einleitung&#8220; _builder_version=&#8220;4.27.4&#8243; background_image=&#8220;https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/imgContatti-1.jpg&#8220; background_position=&#8220;top_center&#8220; background_vertical_offset=&#8220;70%&#8220; custom_margin=&#8220;||||false|false&#8220; custom_padding=&#8220;0px||0px||false|false&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_row use_custom_gutter=&#8220;on&#8220; gutter_width=&#8220;1&#8243; make_equal=&#8220;on&#8220; _builder_version=&#8220;4.27.4&#8243; background_color=&#8220;rgba(33,61,89,0.52)&#8220; width=&#8220;100%&#8220; custom_padding=&#8220;148px||0px|1px|false|false&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_column type=&#8220;4_4&#8243; _builder_version=&#8220;4.27.4&#8243; custom_padding=&#8220;90px|60px|50px|111px|false|false&#8220; custom_padding_tablet=&#8220;140px|40px|20px|40px|false|false&#8220; custom_padding_phone=&#8220;0px|||22px|false|false&#8220; custom_padding_last_edited=&#8220;on|tablet&#8220; custom_css_main_element=&#8220;margin-top:-100px&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_text admin_label=&#8220;Titolo H1 introduzione sito&#8220; _builder_version=&#8220;4.27.4&#8243; text_font=&#8220;&#8211;et_global_body_font||||||||&#8220; text_font_size=&#8220;15px&#8220; text_letter_spacing=&#8220;0.5px&#8220; text_line_height=&#8220;1.4em&#8220; header_font=&#8220;&#8211;et_global_body_font||||||||&#8220; header_text_color=&#8220;#FFFFFF&#8220; header_font_size=&#8220;80px&#8220; header_2_font=&#8220;Nunito||||||||&#8220; header_2_text_color=&#8220;#FFFFFF&#8220; header_2_font_size=&#8220;42px&#8220; custom_margin=&#8220;||30px||false|false&#8220; custom_padding=&#8220;|0px||||&#8220; animation_style=&#8220;slide&#8220; animation_direction=&#8220;bottom&#8220; animation_intensity_slide=&#8220;5%&#8220; locked=&#8220;off&#8220; global_colors_info=&#8220;{}&#8220;]<\/p>\n<h1><b>Ben\u00f6tigen<\/b> Sie<br \/>\n Hilfe<b>?<\/b><\/span><\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8220;1&#8243; module_id=&#8220;Einleitung&#8220; _builder_version=&#8220;4.27.4&#8243; custom_margin=&#8220;||0px||false|false&#8220; custom_padding=&#8220;16px||9px|||&#8220; locked=&#8220;off&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_row column_structure=&#8220;1_2,1_2&#8243; use_custom_gutter=&#8220;on&#8220; gutter_width=&#8220;1&#8243; custom_padding_last_edited=&#8220;on|tablet&#8220; _builder_version=&#8220;4.27.4&#8243; width=&#8220;90%&#8220; custom_padding=&#8220;53px||0px|||&#8220; custom_padding_tablet=&#8220;0px||||false|false&#8220; custom_padding_phone=&#8220;0px||||false|false&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_column type=&#8220;1_2&#8243; _builder_version=&#8220;4.27.4&#8243; custom_padding=&#8220;0px||70px||false|false&#8220; custom_padding_tablet=&#8220;0px||70px||false|false&#8220; custom_padding_phone=&#8220;0px|10px|50px|10px|false|false&#8220; custom_padding_last_edited=&#8220;on|phone&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_text admin_label=&#8220;I nostri articoli&#8220; _builder_version=&#8220;4.27.4&#8243; text_font_size=&#8220;20px&#8220; header_2_font=&#8220;Nunito|600|||||||&#8220; header_2_font_size=&#8220;50px&#8220; header_3_text_color=&#8220;#213D59&#8243; header_3_font_size=&#8220;34px&#8220; header_4_line_height=&#8220;1.1em&#8220; custom_margin=&#8220;59px|||||&#8220; custom_margin_tablet=&#8220;59px|||||&#8220; custom_margin_phone=&#8220;40px||||false|false&#8220; custom_margin_last_edited=&#8220;on|phone&#8220; custom_padding=&#8220;|0px||||&#8220; animation_style=&#8220;slide&#8220; animation_direction=&#8220;left&#8220; animation_intensity_slide=&#8220;5%&#8220; hover_enabled=&#8220;0&#8243; global_colors_info=&#8220;{}&#8220; sticky_enabled=&#8220;0&#8243;]Wir stehen Ihnen gerne zur Verf\u00fcgung, um Ihre Fragen zu beantworten und gemeinsam die beste L\u00f6sung f\u00fcr Ihren Servicebedarf zu finden. [\/et_pb_text][\/et_pb_column][et_pb_column type=&#8220;1_2&#8243; _builder_version=&#8220;4.27.4&#8243; _module_preset=&#8220;default&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_text admin_label=&#8220;Titolo H1 introduzione sito&#8220; _builder_version=&#8220;4.27.4&#8243; text_font=&#8220;&#8211;et_global_body_font||||||||&#8220; text_font_size=&#8220;15px&#8220; text_letter_spacing=&#8220;0.5px&#8220; text_line_height=&#8220;1.4em&#8220; link_text_color=&#8220;#71C9FF&#8220; header_font=&#8220;Helvetica Neue Bold||||||||&#8220; header_font_size=&#8220;80px&#8220; text_orientation=&#8220;right&#8220; max_width=&#8220;74%&#8220; module_alignment=&#8220;right&#8220; custom_margin=&#8220;54px||21px||false|false&#8220; custom_margin_tablet=&#8220;0px||21px||false|false&#8220; custom_margin_phone=&#8220;0px||21px||false|false&#8220; custom_margin_last_edited=&#8220;on|tablet&#8220; animation_style=&#8220;fade&#8220; locked=&#8220;off&#8220; global_colors_info=&#8220;{}&#8220;]<\/p>\n<h3><a href=\"tel:41919719794\"><strong>+41 91 971 97 94<\/strong><\/a><br \/><strong><a href=\"mailto:info@cad.healthcare\">info@cad.healthcare<\/a><\/strong><br \/><strong>Lugano (CH)<\/strong><\/h3>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8220;1&#8243; module_id=&#8220;contactPatient&#8220; _builder_version=&#8220;4.27.4&#8243; _module_preset=&#8220;default&#8220; background_color=&#8220;#F6F6F6&#8243; custom_margin=&#8220;-2px|||||&#8220; custom_padding=&#8220;36px|||||&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_row use_custom_gutter=&#8220;on&#8220; gutter_width=&#8220;1&#8243; _builder_version=&#8220;4.27.4&#8243; width=&#8220;90%&#8220; custom_padding=&#8220;24px||0px||false|false&#8220; locked=&#8220;off&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_column type=&#8220;4_4&#8243; _builder_version=&#8220;4.27.4&#8243; custom_padding=&#8220;|80px|||false|false&#8220; custom_padding_tablet=&#8220;|80px|||false|false&#8220; custom_padding_phone=&#8220;|0px|||false|false&#8220; custom_padding_last_edited=&#8220;on|phone&#8220; global_colors_info=&#8220;{}&#8220;][et_pb_text content_tablet=&#8220;<\/p>\n<h2 class=%22p1%22>Bitte w\u00e4hlen Sie die Art des <b>gew\u00fcnschten Kontakts<\/b>.<\/h2>\n<p>&#8220; content_phone=&#8220;<\/p>\n<h2 class=%22p1%22>Bitte w\u00e4hlen Sie die Art des <b>gew\u00fcnschten Kontakts<\/b>.<\/h2>\n<p>&#8220; content_last_edited=&#8220;off|desktop&#8220; admin_label=&#8220;I nostri articoli&#8220; _builder_version=&#8220;4.27.4&#8243; header_2_font=&#8220;Nunito|600|||||||&#8220; header_2_font_size=&#8220;50px&#8220; header_3_text_color=&#8220;#213D59&#8243; header_3_font_size=&#8220;34px&#8220; custom_margin=&#8220;10px|||||&#8220; custom_padding=&#8220;|42px||||&#8220; custom_padding_tablet=&#8220;|42px||||&#8220; custom_padding_phone=&#8220;|0px|||false|false&#8220; custom_padding_last_edited=&#8220;on|phone&#8220; animation_style=&#8220;slide&#8220; animation_direction=&#8220;left&#8220; animation_intensity_slide=&#8220;5%&#8220; hover_enabled=&#8220;0&#8243; global_colors_info=&#8220;{}&#8220; sticky_enabled=&#8220;0&#8243;]<\/p>\n<h2 class=\"p1\">W\u00e4hlen Sie das<br \/><b>Kontaktformular<\/b>,<br \/>das Sie ben\u00f6tigen.<\/h2>\n<p>[\/et_pb_text][wpforms_selector form_id=&#8220;58&#8243; module_class=&#8220;formScelta&#8220; _builder_version=&#8220;4.27.4&#8243; _module_preset=&#8220;default&#8220; global_colors_info=&#8220;{}&#8220;][\/wpforms_selector][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Ben\u00f6tigen Sie Hilfe?Wir stehen Ihnen gerne zur Verf\u00fcgung, um Ihre Fragen zu beantworten und gemeinsam die beste L\u00f6sung f\u00fcr Ihren Servicebedarf zu finden. +41 91 971 97 94info@cad.healthcareLugano (CH)W\u00e4hlen Sie dasKontaktformular,das Sie ben\u00f6tigen.<div class=\"et_pb_module wpforms_selector wpforms_selector_0 formScelta\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full stileNormale\" id=\"wpforms-58\"><form id=\"wpforms-form-58\" class=\"wpforms-validate wpforms-form\" data-formid=\"58\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/de\/wp-json\/wp\/v2\/pages\/1928\" data-token=\"464ea559c5d6941eff702264168a2c77\" data-token-time=\"1778027635\"><noscript class=\"wpforms-error-noscript\">Bitte aktiviere JavaScript in deinem Browser, um dieses Formular fertigzustellen.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-58-field_9-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"9\"><label class=\"wpforms-field-label wpforms-label-hide\">Art des Kontakts erforderlich: <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_9\" class=\"wpforms-field-required wpforms-image-choices wpforms-image-choices-modern\"><li class=\"choice-1 depth-1 wpforms-image-choices-item wpforms-selected\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_1\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icona-modulo-contatti.png\" alt=\"Kontakt f\u00fcr Patienten\" title=\"Kontakt f\u00fcr Patienten\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_1\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Kontakt f\u00fcr Patienten\" tabindex=\"-1\" required  checked='checked'><span class=\"wpforms-image-choices-label\">Kontakt f\u00fcr Patienten<\/span><\/label><\/li><li class=\"choice-2 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_2\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icone-srtuttura-contatti.png\" alt=\"Kontakt Krankenhaus\/Klinik\" title=\"Kontakt Krankenhaus\/Klinik\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_2\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Kontakt Krankenhaus\/Klinik\" tabindex=\"-1\" required ><span class=\"wpforms-image-choices-label\">Kontakt Krankenhaus\/Klinik<\/span><\/label><\/li><li class=\"choice-3 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_3\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icona-medico-curante-contatti.png\" alt=\"Kontakt Arzt\" title=\"Kontakt Arzt\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_3\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Kontakt Arzt\" tabindex=\"-1\" required ><span class=\"wpforms-image-choices-label\">Kontakt Arzt<\/span><\/label><\/li><\/ul><\/div><div id=\"wpforms-58-field_10-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"10\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPatientendaten\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_3-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"3\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_3\">Vorname Nachname <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"Name und Nachname\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_13-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"13\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_13\">Geburtsdatum <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_13\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][13][date]\" placeholder=\"Geburtsdatum\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_105-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"105\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_105\">Nation<\/label><select id=\"wpforms-58-field_105\" class=\"wpforms-field-large\" name=\"wpforms[fields][105]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanien\"  class=\"choice-5 depth-1\"  >Albanien<\/option><option value=\"Algerien\"  class=\"choice-6 depth-1\"  >Algerien<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarktis\"  class=\"choice-10 depth-1\"  >Antarktis<\/option><option value=\"Antigua und Barbuda\"  class=\"choice-11 depth-1\"  >Antigua und Barbuda<\/option><option value=\"Saudi-Arabien\"  class=\"choice-12 depth-1\"  >Saudi-Arabien<\/option><option value=\"Argentinien\"  class=\"choice-13 depth-1\"  >Argentinien<\/option><option value=\"Armenien\"  class=\"choice-14 depth-1\"  >Armenien<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australien\"  class=\"choice-16 depth-1\"  >Australien<\/option><option value=\"\u00d6sterreich\"  class=\"choice-17 depth-1\"  >\u00d6sterreich<\/option><option value=\"Aserbaidschan\"  class=\"choice-18 depth-1\"  >Aserbaidschan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesch\"  class=\"choice-21 depth-1\"  >Bangladesch<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgien\"  class=\"choice-23 depth-1\"  >Belgien<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Wei\u00dfrussland\"  class=\"choice-28 depth-1\"  >Wei\u00dfrussland<\/option><option value=\"Birma\"  class=\"choice-29 depth-1\"  >Birma<\/option><option value=\"Bolivien (Plurinationaler Staat)\"  class=\"choice-30 depth-1\"  >Bolivien (Plurinationaler Staat)<\/option><option value=\"Bonaire, St. Eustatius und Saba\"  class=\"choice-31 depth-1\"  >Bonaire, St. Eustatius und Saba<\/option><option value=\"Bosnien und Herzegowina\"  class=\"choice-32 depth-1\"  >Bosnien und Herzegowina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brasilien\"  class=\"choice-34 depth-1\"  >Brasilien<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarien\"  class=\"choice-36 depth-1\"  >Bulgarien<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Kambodscha\"  class=\"choice-39 depth-1\"  >Kambodscha<\/option><option value=\"Kamerun\"  class=\"choice-40 depth-1\"  >Kamerun<\/option><option value=\"Kanada\"  class=\"choice-41 depth-1\"  >Kanada<\/option><option value=\"Kap Verde\"  class=\"choice-42 depth-1\"  >Kap Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Zypern\"  class=\"choice-46 depth-1\"  >Zypern<\/option><option value=\"Kolumbien\"  class=\"choice-47 depth-1\"  >Kolumbien<\/option><option value=\"Komoren\"  class=\"choice-48 depth-1\"  >Komoren<\/option><option value=\"Kongo\"  class=\"choice-49 depth-1\"  >Kongo<\/option><option value=\"Kongo (Demokratische Republik)\"  class=\"choice-50 depth-1\"  >Kongo (Demokratische Republik)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Elfenbeink\u00fcste\"  class=\"choice-52 depth-1\"  >Elfenbeink\u00fcste<\/option><option value=\"Kroatien\"  class=\"choice-53 depth-1\"  >Kroatien<\/option><option value=\"Kuba\"  class=\"choice-54 depth-1\"  >Kuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"D\u00e4nemark\"  class=\"choice-56 depth-1\"  >D\u00e4nemark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"\u00c4gypten\"  class=\"choice-59 depth-1\"  >\u00c4gypten<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"Vereinigte Arabische Emirate\"  class=\"choice-61 depth-1\"  >Vereinigte Arabische Emirate<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estland\"  class=\"choice-63 depth-1\"  >Estland<\/option><option value=\"\u00c4thiopien\"  class=\"choice-64 depth-1\"  >\u00c4thiopien<\/option><option value=\"Russische F\u00f6deration\"  class=\"choice-65 depth-1\"  >Russische F\u00f6deration<\/option><option value=\"Fidschi\"  class=\"choice-66 depth-1\"  >Fidschi<\/option><option value=\"Philippinen\"  class=\"choice-67 depth-1\"  >Philippinen<\/option><option value=\"Finnland\"  class=\"choice-68 depth-1\"  >Finnland<\/option><option value=\"Frankreich\"  class=\"choice-69 depth-1\"  >Frankreich<\/option><option value=\"Gabun\"  class=\"choice-70 depth-1\"  >Gabun<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln\"  class=\"choice-73 depth-1\"  >S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln<\/option><option value=\"Deutschland\"  class=\"choice-74 depth-1\"  >Deutschland<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaika\"  class=\"choice-76 depth-1\"  >Jamaika<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Dschibuti\"  class=\"choice-79 depth-1\"  >Dschibuti<\/option><option value=\"Jordanien\"  class=\"choice-80 depth-1\"  >Jordanien<\/option><option value=\"Griechenland\"  class=\"choice-81 depth-1\"  >Griechenland<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Gr\u00f6nland\"  class=\"choice-83 depth-1\"  >Gr\u00f6nland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"Franz\u00f6sisch-Guayana\"  class=\"choice-88 depth-1\"  >Franz\u00f6sisch-Guayana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"\u00c4quatorial-Guinea\"  class=\"choice-90 depth-1\"  >\u00c4quatorial-Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hongkong\"  class=\"choice-95 depth-1\"  >Hongkong<\/option><option value=\"Indien\"  class=\"choice-96 depth-1\"  >Indien<\/option><option value=\"Indonesien\"  class=\"choice-97 depth-1\"  >Indonesien<\/option><option value=\"Iran (Islamische Republik)\"  class=\"choice-98 depth-1\"  >Iran (Islamische Republik)<\/option><option value=\"Irak\"  class=\"choice-99 depth-1\"  >Irak<\/option><option value=\"Irland (Republik)\"  class=\"choice-100 depth-1\"  >Irland (Republik)<\/option><option value=\"Island\"  class=\"choice-101 depth-1\"  >Island<\/option><option value=\"Bouvetinsel\"  class=\"choice-102 depth-1\"  >Bouvetinsel<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Weihnachtsinsel\"  class=\"choice-104 depth-1\"  >Weihnachtsinsel<\/option><option value=\"Insel Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Insel Saint Barth\u00e9lemy<\/option><option value=\"Aland Inseln\"  class=\"choice-106 depth-1\"  >Aland Inseln<\/option><option value=\"Kaimaninseln\"  class=\"choice-107 depth-1\"  >Kaimaninseln<\/option><option value=\"Cocos (Keeling) Inseln\"  class=\"choice-108 depth-1\"  >Cocos (Keeling) Inseln<\/option><option value=\"Cookinseln\"  class=\"choice-109 depth-1\"  >Cookinseln<\/option><option value=\"Falklandinseln (Malwinen)\"  class=\"choice-110 depth-1\"  >Falklandinseln (Malwinen)<\/option><option value=\"F\u00e4r\u00f6er Inseln\"  class=\"choice-111 depth-1\"  >F\u00e4r\u00f6er Inseln<\/option><option value=\"Heard und McDonald Inseln\"  class=\"choice-112 depth-1\"  >Heard und McDonald Inseln<\/option><option value=\"N\u00f6rdliche Marianen\"  class=\"choice-113 depth-1\"  >N\u00f6rdliche Marianen<\/option><option value=\"Marshallinseln\"  class=\"choice-114 depth-1\"  >Marshallinseln<\/option><option value=\"Norfolkinseln\"  class=\"choice-115 depth-1\"  >Norfolkinseln<\/option><option value=\"Saint Pierre und Miquelon Inseln\"  class=\"choice-116 depth-1\"  >Saint Pierre und Miquelon Inseln<\/option><option value=\"Salomonen\"  class=\"choice-117 depth-1\"  >Salomonen<\/option><option value=\"Svalbard und Jan Mayen Inseln\"  class=\"choice-118 depth-1\"  >Svalbard und Jan Mayen Inseln<\/option><option value=\"Turks- und Caicosinseln\"  class=\"choice-119 depth-1\"  >Turks- und Caicosinseln<\/option><option value=\"Jungferninseln (US)\"  class=\"choice-120 depth-1\"  >Jungferninseln (US)<\/option><option value=\"Jungferninseln (Britisch)\"  class=\"choice-121 depth-1\"  >Jungferninseln (Britisch)<\/option><option value=\"United States Minor Outlying Islands\"  class=\"choice-122 depth-1\"  >United States Minor Outlying Islands<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italien\"  class=\"choice-124 depth-1\"  >Italien<\/option><option value=\"Kasachstan\"  class=\"choice-125 depth-1\"  >Kasachstan<\/option><option value=\"Kenia\"  class=\"choice-126 depth-1\"  >Kenia<\/option><option value=\"Kirgisistan\"  class=\"choice-127 depth-1\"  >Kirgisistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (Demokratische Volksrepublik)\"  class=\"choice-129 depth-1\"  >Korea (Demokratische Volksrepublik)<\/option><option value=\"Korea (Republik)\"  class=\"choice-130 depth-1\"  >Korea (Republik)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettland\"  class=\"choice-134 depth-1\"  >Lettland<\/option><option value=\"Libanon\"  class=\"choice-135 depth-1\"  >Libanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libyen\"  class=\"choice-137 depth-1\"  >Libyen<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Litauen\"  class=\"choice-139 depth-1\"  >Litauen<\/option><option value=\"Luxemburg\"  class=\"choice-140 depth-1\"  >Luxemburg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Nord-Mazedonien (Republik)\"  class=\"choice-142 depth-1\"  >Nord-Mazedonien (Republik)<\/option><option value=\"Madagaskar\"  class=\"choice-143 depth-1\"  >Madagaskar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Malediven\"  class=\"choice-146 depth-1\"  >Malediven<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Marokko\"  class=\"choice-150 depth-1\"  >Marokko<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauretanien\"  class=\"choice-152 depth-1\"  >Mauretanien<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexiko\"  class=\"choice-155 depth-1\"  >Mexiko<\/option><option value=\"Mikronesien (Konf\u00f6deration der Staaten von)\"  class=\"choice-156 depth-1\"  >Mikronesien (Konf\u00f6deration der Staaten von)<\/option><option value=\"Moldawien (Republik)\"  class=\"choice-157 depth-1\"  >Moldawien (Republik)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolei\"  class=\"choice-159 depth-1\"  >Mongolei<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mosambik\"  class=\"choice-162 depth-1\"  >Mosambik<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norwegen\"  class=\"choice-170 depth-1\"  >Norwegen<\/option><option value=\"Neukaledonien\"  class=\"choice-171 depth-1\"  >Neukaledonien<\/option><option value=\"Neuseeland\"  class=\"choice-172 depth-1\"  >Neuseeland<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Die Niederlande\"  class=\"choice-174 depth-1\"  >Die Niederlande<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Pal\u00e4stina (Staat)\"  class=\"choice-177 depth-1\"  >Pal\u00e4stina (Staat)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua-Neuguinea\"  class=\"choice-179 depth-1\"  >Papua-Neuguinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Polen\"  class=\"choice-183 depth-1\"  >Polen<\/option><option value=\"Franz\u00f6sisch-Polynesien\"  class=\"choice-184 depth-1\"  >Franz\u00f6sisch-Polynesien<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Katar\"  class=\"choice-187 depth-1\"  >Katar<\/option><option value=\"Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland\"  class=\"choice-188 depth-1\"  >Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland<\/option><option value=\"Arabische Republik Syrien\"  class=\"choice-189 depth-1\"  >Arabische Republik Syrien<\/option><option value=\"Tschechische Republik\"  class=\"choice-190 depth-1\"  >Tschechische Republik<\/option><option value=\"Zentralafrikanische Republik\"  class=\"choice-191 depth-1\"  >Zentralafrikanische Republik<\/option><option value=\"Demokratische Volksrepublik Laos\"  class=\"choice-192 depth-1\"  >Demokratische Volksrepublik Laos<\/option><option value=\"Dominikanische Republik\"  class=\"choice-193 depth-1\"  >Dominikanische Republik<\/option><option value=\"La R\u00e9union (Insel)\"  class=\"choice-194 depth-1\"  >La R\u00e9union (Insel)<\/option><option value=\"Rum\u00e4nien\"  class=\"choice-195 depth-1\"  >Rum\u00e4nien<\/option><option value=\"Ruanda\"  class=\"choice-196 depth-1\"  >Ruanda<\/option><option value=\"Westsahara\"  class=\"choice-197 depth-1\"  >Westsahara<\/option><option value=\"St. Kitts und Nevis\"  class=\"choice-198 depth-1\"  >St. Kitts und Nevis<\/option><option value=\"St. Vincent und die Grenadinen\"  class=\"choice-199 depth-1\"  >St. Vincent und die Grenadinen<\/option><option value=\"Saint-Martin (franz\u00f6sischer Teil)\"  class=\"choice-200 depth-1\"  >Saint-Martin (franz\u00f6sischer Teil)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Amerikanisch-Samoa\"  class=\"choice-202 depth-1\"  >Amerikanisch-Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension und Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension und Tristan da Cunha<\/option><option value=\"St. Lucia\"  class=\"choice-205 depth-1\"  >St. Lucia<\/option><option value=\"Sao Tome und Principe\"  class=\"choice-206 depth-1\"  >Sao Tome und Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbien\"  class=\"choice-208 depth-1\"  >Serbien<\/option><option value=\"Seychellen\"  class=\"choice-209 depth-1\"  >Seychellen<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapur\"  class=\"choice-211 depth-1\"  >Singapur<\/option><option value=\"Sint Maarten (Teil der Niederlande)\"  class=\"choice-212 depth-1\"  >Sint Maarten (Teil der Niederlande)<\/option><option value=\"Slowakei\"  class=\"choice-213 depth-1\"  >Slowakei<\/option><option value=\"Slowenien\"  class=\"choice-214 depth-1\"  >Slowenien<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spanien\"  class=\"choice-216 depth-1\"  >Spanien<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"Vereinigte Staaten von Amerika\"  class=\"choice-218 depth-1\"  >Vereinigte Staaten von Amerika<\/option><option value=\"Staat Vatikanstadt\"  class=\"choice-219 depth-1\"  >Staat Vatikanstadt<\/option><option value=\"S\u00fcdafrika\"  class=\"choice-220 depth-1\"  >S\u00fcdafrika<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"S\u00fcdsudan\"  class=\"choice-222 depth-1\"  >S\u00fcdsudan<\/option><option value=\"Surinam\"  class=\"choice-223 depth-1\"  >Surinam<\/option><option value=\"Schweden\"  class=\"choice-224 depth-1\"  >Schweden<\/option><option value=\"Schweiz\"  selected='selected' class=\"choice-225 depth-1\"  >Schweiz<\/option><option value=\"Tadschikistan\"  class=\"choice-226 depth-1\"  >Tadschikistan<\/option><option value=\"Taiwan, Republik China\"  class=\"choice-227 depth-1\"  >Taiwan, Republik China<\/option><option value=\"Tansania (Vereinigte Republik)\"  class=\"choice-228 depth-1\"  >Tansania (Vereinigte Republik)<\/option><option value=\"Franz\u00f6sische S\u00fcd-Territorien\"  class=\"choice-229 depth-1\"  >Franz\u00f6sische S\u00fcd-Territorien<\/option><option value=\"Britisches Territorium im Indischen Ozean\"  class=\"choice-230 depth-1\"  >Britisches Territorium im Indischen Ozean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"Osttimor\"  class=\"choice-232 depth-1\"  >Osttimor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad und Tobago\"  class=\"choice-236 depth-1\"  >Trinidad und Tobago<\/option><option value=\"Tunesien\"  class=\"choice-237 depth-1\"  >Tunesien<\/option><option value=\"T\u00fcrkei\"  class=\"choice-238 depth-1\"  >T\u00fcrkei<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Ungarn\"  class=\"choice-243 depth-1\"  >Ungarn<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Usbekistan\"  class=\"choice-245 depth-1\"  >Usbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivianische Republik)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivianische Republik)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis und Futuna\"  class=\"choice-249 depth-1\"  >Wallis und Futuna<\/option><option value=\"Jemen\"  class=\"choice-250 depth-1\"  >Jemen<\/option><option value=\"Sambia\"  class=\"choice-251 depth-1\"  >Sambia<\/option><option value=\"Simbabwe\"  class=\"choice-252 depth-1\"  >Simbabwe<\/option><option value=\"eSwatini (K\u00f6nigreich)\"  class=\"choice-253 depth-1\"  >eSwatini (K\u00f6nigreich)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_12-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_12\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_12\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][12][address1]\" placeholder=\"Adresse\" required><label for=\"wpforms-58-field_12\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse Zeile 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_12-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][12][city]\" placeholder=\"St\u00e4dte\" required><label for=\"wpforms-58-field_12-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Stadt<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_12-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][12][state]\" placeholder=\"Kanton\" required><label for=\"wpforms-58-field_12-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_4-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"4\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_4\">Telefon <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_4\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][4]\" placeholder=\"Telefon\" aria-label=\"Telefon\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_1-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"1\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_1\">E-Mail<\/label><input type=\"email\" id=\"wpforms-58-field_1\" class=\"wpforms-field-large\" name=\"wpforms[fields][1]\" placeholder=\"E-Mail\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_14-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"14\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tKontaktinformationen (falls abweichend vom Patienten)\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_21\">vorname nachname<\/label><input type=\"text\" id=\"wpforms-58-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" placeholder=\"Name und Nachname\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_16-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"16\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_16\">Geburtsdatum<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_16\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][16][date]\" placeholder=\"Geburtsdatum\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_107-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"107\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_107\">Land Kontakt<\/label><select id=\"wpforms-58-field_107\" class=\"wpforms-field-large\" name=\"wpforms[fields][107]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanien\"  class=\"choice-5 depth-1\"  >Albanien<\/option><option value=\"Algerien\"  class=\"choice-6 depth-1\"  >Algerien<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarktis\"  class=\"choice-10 depth-1\"  >Antarktis<\/option><option value=\"Antigua und Barbuda\"  class=\"choice-11 depth-1\"  >Antigua und Barbuda<\/option><option value=\"Saudi-Arabien\"  class=\"choice-12 depth-1\"  >Saudi-Arabien<\/option><option value=\"Argentinien\"  class=\"choice-13 depth-1\"  >Argentinien<\/option><option value=\"Armenien\"  class=\"choice-14 depth-1\"  >Armenien<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australien\"  class=\"choice-16 depth-1\"  >Australien<\/option><option value=\"\u00d6sterreich\"  class=\"choice-17 depth-1\"  >\u00d6sterreich<\/option><option value=\"Aserbaidschan\"  class=\"choice-18 depth-1\"  >Aserbaidschan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesch\"  class=\"choice-21 depth-1\"  >Bangladesch<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgien\"  class=\"choice-23 depth-1\"  >Belgien<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Wei\u00dfrussland\"  class=\"choice-28 depth-1\"  >Wei\u00dfrussland<\/option><option value=\"Birma\"  class=\"choice-29 depth-1\"  >Birma<\/option><option value=\"Bolivien (Plurinationaler Staat)\"  class=\"choice-30 depth-1\"  >Bolivien (Plurinationaler Staat)<\/option><option value=\"Bonaire, St. Eustatius und Saba\"  class=\"choice-31 depth-1\"  >Bonaire, St. Eustatius und Saba<\/option><option value=\"Bosnien und Herzegowina\"  class=\"choice-32 depth-1\"  >Bosnien und Herzegowina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brasilien\"  class=\"choice-34 depth-1\"  >Brasilien<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarien\"  class=\"choice-36 depth-1\"  >Bulgarien<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Kambodscha\"  class=\"choice-39 depth-1\"  >Kambodscha<\/option><option value=\"Kamerun\"  class=\"choice-40 depth-1\"  >Kamerun<\/option><option value=\"Kanada\"  class=\"choice-41 depth-1\"  >Kanada<\/option><option value=\"Kap Verde\"  class=\"choice-42 depth-1\"  >Kap Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Zypern\"  class=\"choice-46 depth-1\"  >Zypern<\/option><option value=\"Kolumbien\"  class=\"choice-47 depth-1\"  >Kolumbien<\/option><option value=\"Komoren\"  class=\"choice-48 depth-1\"  >Komoren<\/option><option value=\"Kongo\"  class=\"choice-49 depth-1\"  >Kongo<\/option><option value=\"Kongo (Demokratische Republik)\"  class=\"choice-50 depth-1\"  >Kongo (Demokratische Republik)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Elfenbeink\u00fcste\"  class=\"choice-52 depth-1\"  >Elfenbeink\u00fcste<\/option><option value=\"Kroatien\"  class=\"choice-53 depth-1\"  >Kroatien<\/option><option value=\"Kuba\"  class=\"choice-54 depth-1\"  >Kuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"D\u00e4nemark\"  class=\"choice-56 depth-1\"  >D\u00e4nemark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"\u00c4gypten\"  class=\"choice-59 depth-1\"  >\u00c4gypten<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"Vereinigte Arabische Emirate\"  class=\"choice-61 depth-1\"  >Vereinigte Arabische Emirate<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estland\"  class=\"choice-63 depth-1\"  >Estland<\/option><option value=\"\u00c4thiopien\"  class=\"choice-64 depth-1\"  >\u00c4thiopien<\/option><option value=\"Russische F\u00f6deration\"  class=\"choice-65 depth-1\"  >Russische F\u00f6deration<\/option><option value=\"Fidschi\"  class=\"choice-66 depth-1\"  >Fidschi<\/option><option value=\"Philippinen\"  class=\"choice-67 depth-1\"  >Philippinen<\/option><option value=\"Finnland\"  class=\"choice-68 depth-1\"  >Finnland<\/option><option value=\"Frankreich\"  class=\"choice-69 depth-1\"  >Frankreich<\/option><option value=\"Gabun\"  class=\"choice-70 depth-1\"  >Gabun<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln\"  class=\"choice-73 depth-1\"  >S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln<\/option><option value=\"Deutschland\"  class=\"choice-74 depth-1\"  >Deutschland<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaika\"  class=\"choice-76 depth-1\"  >Jamaika<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Dschibuti\"  class=\"choice-79 depth-1\"  >Dschibuti<\/option><option value=\"Jordanien\"  class=\"choice-80 depth-1\"  >Jordanien<\/option><option value=\"Griechenland\"  class=\"choice-81 depth-1\"  >Griechenland<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Gr\u00f6nland\"  class=\"choice-83 depth-1\"  >Gr\u00f6nland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"Franz\u00f6sisch-Guayana\"  class=\"choice-88 depth-1\"  >Franz\u00f6sisch-Guayana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"\u00c4quatorial-Guinea\"  class=\"choice-90 depth-1\"  >\u00c4quatorial-Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hongkong\"  class=\"choice-95 depth-1\"  >Hongkong<\/option><option value=\"Indien\"  class=\"choice-96 depth-1\"  >Indien<\/option><option value=\"Indonesien\"  class=\"choice-97 depth-1\"  >Indonesien<\/option><option value=\"Iran (Islamische Republik)\"  class=\"choice-98 depth-1\"  >Iran (Islamische Republik)<\/option><option value=\"Irak\"  class=\"choice-99 depth-1\"  >Irak<\/option><option value=\"Irland (Republik)\"  class=\"choice-100 depth-1\"  >Irland (Republik)<\/option><option value=\"Island\"  class=\"choice-101 depth-1\"  >Island<\/option><option value=\"Bouvetinsel\"  class=\"choice-102 depth-1\"  >Bouvetinsel<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Weihnachtsinsel\"  class=\"choice-104 depth-1\"  >Weihnachtsinsel<\/option><option value=\"Insel Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Insel Saint Barth\u00e9lemy<\/option><option value=\"Aland Inseln\"  class=\"choice-106 depth-1\"  >Aland Inseln<\/option><option value=\"Kaimaninseln\"  class=\"choice-107 depth-1\"  >Kaimaninseln<\/option><option value=\"Cocos (Keeling) Inseln\"  class=\"choice-108 depth-1\"  >Cocos (Keeling) Inseln<\/option><option value=\"Cookinseln\"  class=\"choice-109 depth-1\"  >Cookinseln<\/option><option value=\"Falklandinseln (Malwinen)\"  class=\"choice-110 depth-1\"  >Falklandinseln (Malwinen)<\/option><option value=\"F\u00e4r\u00f6er Inseln\"  class=\"choice-111 depth-1\"  >F\u00e4r\u00f6er Inseln<\/option><option value=\"Heard und McDonald Inseln\"  class=\"choice-112 depth-1\"  >Heard und McDonald Inseln<\/option><option value=\"N\u00f6rdliche Marianen\"  class=\"choice-113 depth-1\"  >N\u00f6rdliche Marianen<\/option><option value=\"Marshallinseln\"  class=\"choice-114 depth-1\"  >Marshallinseln<\/option><option value=\"Norfolkinseln\"  class=\"choice-115 depth-1\"  >Norfolkinseln<\/option><option value=\"Saint Pierre und Miquelon Inseln\"  class=\"choice-116 depth-1\"  >Saint Pierre und Miquelon Inseln<\/option><option value=\"Salomonen\"  class=\"choice-117 depth-1\"  >Salomonen<\/option><option value=\"Svalbard und Jan Mayen Inseln\"  class=\"choice-118 depth-1\"  >Svalbard und Jan Mayen Inseln<\/option><option value=\"Turks- und Caicosinseln\"  class=\"choice-119 depth-1\"  >Turks- und Caicosinseln<\/option><option value=\"Jungferninseln (US)\"  class=\"choice-120 depth-1\"  >Jungferninseln (US)<\/option><option value=\"Jungferninseln (Britisch)\"  class=\"choice-121 depth-1\"  >Jungferninseln (Britisch)<\/option><option value=\"United States Minor Outlying Islands\"  class=\"choice-122 depth-1\"  >United States Minor Outlying Islands<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italien\"  class=\"choice-124 depth-1\"  >Italien<\/option><option value=\"Kasachstan\"  class=\"choice-125 depth-1\"  >Kasachstan<\/option><option value=\"Kenia\"  class=\"choice-126 depth-1\"  >Kenia<\/option><option value=\"Kirgisistan\"  class=\"choice-127 depth-1\"  >Kirgisistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (Demokratische Volksrepublik)\"  class=\"choice-129 depth-1\"  >Korea (Demokratische Volksrepublik)<\/option><option value=\"Korea (Republik)\"  class=\"choice-130 depth-1\"  >Korea (Republik)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettland\"  class=\"choice-134 depth-1\"  >Lettland<\/option><option value=\"Libanon\"  class=\"choice-135 depth-1\"  >Libanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libyen\"  class=\"choice-137 depth-1\"  >Libyen<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Litauen\"  class=\"choice-139 depth-1\"  >Litauen<\/option><option value=\"Luxemburg\"  class=\"choice-140 depth-1\"  >Luxemburg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Nord-Mazedonien (Republik)\"  class=\"choice-142 depth-1\"  >Nord-Mazedonien (Republik)<\/option><option value=\"Madagaskar\"  class=\"choice-143 depth-1\"  >Madagaskar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Malediven\"  class=\"choice-146 depth-1\"  >Malediven<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Marokko\"  class=\"choice-150 depth-1\"  >Marokko<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauretanien\"  class=\"choice-152 depth-1\"  >Mauretanien<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexiko\"  class=\"choice-155 depth-1\"  >Mexiko<\/option><option value=\"Mikronesien (Konf\u00f6deration der Staaten von)\"  class=\"choice-156 depth-1\"  >Mikronesien (Konf\u00f6deration der Staaten von)<\/option><option value=\"Moldawien (Republik)\"  class=\"choice-157 depth-1\"  >Moldawien (Republik)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolei\"  class=\"choice-159 depth-1\"  >Mongolei<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mosambik\"  class=\"choice-162 depth-1\"  >Mosambik<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norwegen\"  class=\"choice-170 depth-1\"  >Norwegen<\/option><option value=\"Neukaledonien\"  class=\"choice-171 depth-1\"  >Neukaledonien<\/option><option value=\"Neuseeland\"  class=\"choice-172 depth-1\"  >Neuseeland<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Die Niederlande\"  class=\"choice-174 depth-1\"  >Die Niederlande<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Pal\u00e4stina (Staat)\"  class=\"choice-177 depth-1\"  >Pal\u00e4stina (Staat)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua-Neuguinea\"  class=\"choice-179 depth-1\"  >Papua-Neuguinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Polen\"  class=\"choice-183 depth-1\"  >Polen<\/option><option value=\"Franz\u00f6sisch-Polynesien\"  class=\"choice-184 depth-1\"  >Franz\u00f6sisch-Polynesien<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Katar\"  class=\"choice-187 depth-1\"  >Katar<\/option><option value=\"Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland\"  class=\"choice-188 depth-1\"  >Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland<\/option><option value=\"Arabische Republik Syrien\"  class=\"choice-189 depth-1\"  >Arabische Republik Syrien<\/option><option value=\"Tschechische Republik\"  class=\"choice-190 depth-1\"  >Tschechische Republik<\/option><option value=\"Zentralafrikanische Republik\"  class=\"choice-191 depth-1\"  >Zentralafrikanische Republik<\/option><option value=\"Demokratische Volksrepublik Laos\"  class=\"choice-192 depth-1\"  >Demokratische Volksrepublik Laos<\/option><option value=\"Dominikanische Republik\"  class=\"choice-193 depth-1\"  >Dominikanische Republik<\/option><option value=\"La R\u00e9union (Insel)\"  class=\"choice-194 depth-1\"  >La R\u00e9union (Insel)<\/option><option value=\"Rum\u00e4nien\"  class=\"choice-195 depth-1\"  >Rum\u00e4nien<\/option><option value=\"Ruanda\"  class=\"choice-196 depth-1\"  >Ruanda<\/option><option value=\"Westsahara\"  class=\"choice-197 depth-1\"  >Westsahara<\/option><option value=\"St. Kitts und Nevis\"  class=\"choice-198 depth-1\"  >St. Kitts und Nevis<\/option><option value=\"St. Vincent und die Grenadinen\"  class=\"choice-199 depth-1\"  >St. Vincent und die Grenadinen<\/option><option value=\"Saint-Martin (franz\u00f6sischer Teil)\"  class=\"choice-200 depth-1\"  >Saint-Martin (franz\u00f6sischer Teil)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Amerikanisch-Samoa\"  class=\"choice-202 depth-1\"  >Amerikanisch-Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension und Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension und Tristan da Cunha<\/option><option value=\"St. Lucia\"  class=\"choice-205 depth-1\"  >St. Lucia<\/option><option value=\"Sao Tome und Principe\"  class=\"choice-206 depth-1\"  >Sao Tome und Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbien\"  class=\"choice-208 depth-1\"  >Serbien<\/option><option value=\"Seychellen\"  class=\"choice-209 depth-1\"  >Seychellen<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapur\"  class=\"choice-211 depth-1\"  >Singapur<\/option><option value=\"Sint Maarten (Teil der Niederlande)\"  class=\"choice-212 depth-1\"  >Sint Maarten (Teil der Niederlande)<\/option><option value=\"Slowakei\"  class=\"choice-213 depth-1\"  >Slowakei<\/option><option value=\"Slowenien\"  class=\"choice-214 depth-1\"  >Slowenien<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spanien\"  class=\"choice-216 depth-1\"  >Spanien<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"Vereinigte Staaten von Amerika\"  class=\"choice-218 depth-1\"  >Vereinigte Staaten von Amerika<\/option><option value=\"Staat Vatikanstadt\"  class=\"choice-219 depth-1\"  >Staat Vatikanstadt<\/option><option value=\"S\u00fcdafrika\"  class=\"choice-220 depth-1\"  >S\u00fcdafrika<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"S\u00fcdsudan\"  class=\"choice-222 depth-1\"  >S\u00fcdsudan<\/option><option value=\"Surinam\"  class=\"choice-223 depth-1\"  >Surinam<\/option><option value=\"Schweden\"  class=\"choice-224 depth-1\"  >Schweden<\/option><option value=\"Schweiz\"  selected='selected' class=\"choice-225 depth-1\"  >Schweiz<\/option><option value=\"Tadschikistan\"  class=\"choice-226 depth-1\"  >Tadschikistan<\/option><option value=\"Taiwan, Republik China\"  class=\"choice-227 depth-1\"  >Taiwan, Republik China<\/option><option value=\"Tansania (Vereinigte Republik)\"  class=\"choice-228 depth-1\"  >Tansania (Vereinigte Republik)<\/option><option value=\"Franz\u00f6sische S\u00fcd-Territorien\"  class=\"choice-229 depth-1\"  >Franz\u00f6sische S\u00fcd-Territorien<\/option><option value=\"Britisches Territorium im Indischen Ozean\"  class=\"choice-230 depth-1\"  >Britisches Territorium im Indischen Ozean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"Osttimor\"  class=\"choice-232 depth-1\"  >Osttimor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad und Tobago\"  class=\"choice-236 depth-1\"  >Trinidad und Tobago<\/option><option value=\"Tunesien\"  class=\"choice-237 depth-1\"  >Tunesien<\/option><option value=\"T\u00fcrkei\"  class=\"choice-238 depth-1\"  >T\u00fcrkei<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Ungarn\"  class=\"choice-243 depth-1\"  >Ungarn<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Usbekistan\"  class=\"choice-245 depth-1\"  >Usbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivianische Republik)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivianische Republik)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis und Futuna\"  class=\"choice-249 depth-1\"  >Wallis und Futuna<\/option><option value=\"Jemen\"  class=\"choice-250 depth-1\"  >Jemen<\/option><option value=\"Sambia\"  class=\"choice-251 depth-1\"  >Sambia<\/option><option value=\"Simbabwe\"  class=\"choice-252 depth-1\"  >Simbabwe<\/option><option value=\"eSwatini (K\u00f6nigreich)\"  class=\"choice-253 depth-1\"  >eSwatini (K\u00f6nigreich)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_17-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"17\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_17\">Kontaktadresse<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_17\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][17][address1]\" placeholder=\"Adresse\" ><label for=\"wpforms-58-field_17\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse Zeile 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_17-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][17][city]\" placeholder=\"St\u00e4dte\" ><label for=\"wpforms-58-field_17-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Stadt<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_17-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][17][state]\" placeholder=\"Kanton\" ><label for=\"wpforms-58-field_17-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_18-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"18\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_18\">Telefon<\/label><input type=\"tel\" id=\"wpforms-58-field_18\" class=\"wpforms-field-large\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][18]\" placeholder=\"Telefon\" aria-label=\"Telefon\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_19-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_19\">E-Mail<\/label><input type=\"email\" id=\"wpforms-58-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" placeholder=\"E-Mail\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_83-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"83\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tGrund f\u00fcr die Kontaktaufnahme\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_84-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"84\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_84\">Hauptdiagnose<\/label><input type=\"text\" id=\"wpforms-58-field_84\" class=\"wpforms-field-large\" name=\"wpforms[fields][84]\" placeholder=\"Spezifische Hauptdiagnose\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_87-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_87\">Spezifische Nebendiagnosen  <\/label><input type=\"text\" id=\"wpforms-58-field_87\" class=\"wpforms-field-large\" name=\"wpforms[fields][87]\" placeholder=\"Grundlegende Nebendiagnosen\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_85-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\">Erforderliche Dienstleistungen<\/label><ul id=\"wpforms-58-field_85\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_1\" name=\"wpforms[fields][85][]\" value=\"Grundlegende Pflegeleistungen\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_1\">Grundlegende Pflegeleistungen<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_2\" name=\"wpforms[fields][85][]\" value=\"Pflegedienste\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_2\">Pflegedienste<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_4\" name=\"wpforms[fields][85][]\" value=\"Spezialisierte Pflegedienste\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_4\">Spezialisierte Pflegedienste<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_7\" name=\"wpforms[fields][85][]\" value=\"Private Dienstleistungen\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_7\">Private Dienstleistungen<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_6\" name=\"wpforms[fields][85][]\" value=\"Internationale Leistung\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_6\">Internationale Leistung<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_9\" name=\"wpforms[fields][85][]\" value=\"Telemedizinischer Dienst\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_9\">Telemedizinischer Dienst<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_8\" name=\"wpforms[fields][85][]\" value=\"Telecare-Dienst\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_8\">Telecare-Dienst<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_88-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"88\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_88\">Anzahl der erforderlichen Interventionen<\/label><input type=\"text\" id=\"wpforms-58-field_88\" class=\"wpforms-field-large\" name=\"wpforms[fields][88]\" placeholder=\"Bestimmte Anzahl von Interventionen\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_86-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"86\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_86\">Aufforderung, die Verantwortung zu \u00fcbernehmen<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_86\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][86][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_24-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tGrad der Priorit\u00e4t\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">Grad der Priorit\u00e4t <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_1\" name=\"wpforms[fields][30]\" value=\"Niedrig\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_1\">Niedrig<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_2\" name=\"wpforms[fields][30]\" value=\"Medium\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_2\">Medium<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_3\" name=\"wpforms[fields][30]\" value=\"Hoch\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_3\">Hoch<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_4\" name=\"wpforms[fields][30]\" value=\"Anfrage nach ausf\u00fchrlichen Informationen \u00fcber den Service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_4\">Anfrage nach ausf\u00fchrlichen Informationen \u00fcber den Service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_28-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_28\">Zus\u00e4tzlicher Text - Grad der Priorit\u00e4t<\/label><textarea id=\"wpforms-58-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" placeholder=\"Zus\u00e4tzlicher Text\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_37-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tBitte f\u00fcllen Sie die folgenden Felder aus:\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_38\">Antragsteller Struktur Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_38\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][38]\" placeholder=\"Name des antragstellenden Unternehmens eingeben\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_39-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_39\">Kontaktperson der antragstellenden Einrichtung und entsprechende Funktion <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_39\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][39]\" placeholder=\"Kontaktname eingeben\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_104-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"104\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_104\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_104\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][104]\" placeholder=\"Geben Sie eine Adresse ein\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_41-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPatientendaten\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_42-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"42\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_42\">vorname nachname <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_42\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][42]\" placeholder=\"Name und Nachname\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_43-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_43\">Geburtsdatum <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_43\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][43][date]\" placeholder=\"Geburtsdatum\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_108-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"108\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_108\">Land Patient<\/label><select id=\"wpforms-58-field_108\" class=\"wpforms-field-large\" name=\"wpforms[fields][108]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanien\"  class=\"choice-5 depth-1\"  >Albanien<\/option><option value=\"Algerien\"  class=\"choice-6 depth-1\"  >Algerien<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarktis\"  class=\"choice-10 depth-1\"  >Antarktis<\/option><option value=\"Antigua und Barbuda\"  class=\"choice-11 depth-1\"  >Antigua und Barbuda<\/option><option value=\"Saudi-Arabien\"  class=\"choice-12 depth-1\"  >Saudi-Arabien<\/option><option value=\"Argentinien\"  class=\"choice-13 depth-1\"  >Argentinien<\/option><option value=\"Armenien\"  class=\"choice-14 depth-1\"  >Armenien<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australien\"  class=\"choice-16 depth-1\"  >Australien<\/option><option value=\"\u00d6sterreich\"  class=\"choice-17 depth-1\"  >\u00d6sterreich<\/option><option value=\"Aserbaidschan\"  class=\"choice-18 depth-1\"  >Aserbaidschan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesch\"  class=\"choice-21 depth-1\"  >Bangladesch<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgien\"  class=\"choice-23 depth-1\"  >Belgien<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Wei\u00dfrussland\"  class=\"choice-28 depth-1\"  >Wei\u00dfrussland<\/option><option value=\"Birma\"  class=\"choice-29 depth-1\"  >Birma<\/option><option value=\"Bolivien (Plurinationaler Staat)\"  class=\"choice-30 depth-1\"  >Bolivien (Plurinationaler Staat)<\/option><option value=\"Bonaire, St. Eustatius und Saba\"  class=\"choice-31 depth-1\"  >Bonaire, St. Eustatius und Saba<\/option><option value=\"Bosnien und Herzegowina\"  class=\"choice-32 depth-1\"  >Bosnien und Herzegowina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brasilien\"  class=\"choice-34 depth-1\"  >Brasilien<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarien\"  class=\"choice-36 depth-1\"  >Bulgarien<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Kambodscha\"  class=\"choice-39 depth-1\"  >Kambodscha<\/option><option value=\"Kamerun\"  class=\"choice-40 depth-1\"  >Kamerun<\/option><option value=\"Kanada\"  class=\"choice-41 depth-1\"  >Kanada<\/option><option value=\"Kap Verde\"  class=\"choice-42 depth-1\"  >Kap Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Zypern\"  class=\"choice-46 depth-1\"  >Zypern<\/option><option value=\"Kolumbien\"  class=\"choice-47 depth-1\"  >Kolumbien<\/option><option value=\"Komoren\"  class=\"choice-48 depth-1\"  >Komoren<\/option><option value=\"Kongo\"  class=\"choice-49 depth-1\"  >Kongo<\/option><option value=\"Kongo (Demokratische Republik)\"  class=\"choice-50 depth-1\"  >Kongo (Demokratische Republik)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Elfenbeink\u00fcste\"  class=\"choice-52 depth-1\"  >Elfenbeink\u00fcste<\/option><option value=\"Kroatien\"  class=\"choice-53 depth-1\"  >Kroatien<\/option><option value=\"Kuba\"  class=\"choice-54 depth-1\"  >Kuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"D\u00e4nemark\"  class=\"choice-56 depth-1\"  >D\u00e4nemark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"\u00c4gypten\"  class=\"choice-59 depth-1\"  >\u00c4gypten<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"Vereinigte Arabische Emirate\"  class=\"choice-61 depth-1\"  >Vereinigte Arabische Emirate<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estland\"  class=\"choice-63 depth-1\"  >Estland<\/option><option value=\"\u00c4thiopien\"  class=\"choice-64 depth-1\"  >\u00c4thiopien<\/option><option value=\"Russische F\u00f6deration\"  class=\"choice-65 depth-1\"  >Russische F\u00f6deration<\/option><option value=\"Fidschi\"  class=\"choice-66 depth-1\"  >Fidschi<\/option><option value=\"Philippinen\"  class=\"choice-67 depth-1\"  >Philippinen<\/option><option value=\"Finnland\"  class=\"choice-68 depth-1\"  >Finnland<\/option><option value=\"Frankreich\"  class=\"choice-69 depth-1\"  >Frankreich<\/option><option value=\"Gabun\"  class=\"choice-70 depth-1\"  >Gabun<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln\"  class=\"choice-73 depth-1\"  >S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln<\/option><option value=\"Deutschland\"  class=\"choice-74 depth-1\"  >Deutschland<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaika\"  class=\"choice-76 depth-1\"  >Jamaika<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Dschibuti\"  class=\"choice-79 depth-1\"  >Dschibuti<\/option><option value=\"Jordanien\"  class=\"choice-80 depth-1\"  >Jordanien<\/option><option value=\"Griechenland\"  class=\"choice-81 depth-1\"  >Griechenland<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Gr\u00f6nland\"  class=\"choice-83 depth-1\"  >Gr\u00f6nland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"Franz\u00f6sisch-Guayana\"  class=\"choice-88 depth-1\"  >Franz\u00f6sisch-Guayana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"\u00c4quatorial-Guinea\"  class=\"choice-90 depth-1\"  >\u00c4quatorial-Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hongkong\"  class=\"choice-95 depth-1\"  >Hongkong<\/option><option value=\"Indien\"  class=\"choice-96 depth-1\"  >Indien<\/option><option value=\"Indonesien\"  class=\"choice-97 depth-1\"  >Indonesien<\/option><option value=\"Iran (Islamische Republik)\"  class=\"choice-98 depth-1\"  >Iran (Islamische Republik)<\/option><option value=\"Irak\"  class=\"choice-99 depth-1\"  >Irak<\/option><option value=\"Irland (Republik)\"  class=\"choice-100 depth-1\"  >Irland (Republik)<\/option><option value=\"Island\"  class=\"choice-101 depth-1\"  >Island<\/option><option value=\"Bouvetinsel\"  class=\"choice-102 depth-1\"  >Bouvetinsel<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Weihnachtsinsel\"  class=\"choice-104 depth-1\"  >Weihnachtsinsel<\/option><option value=\"Insel Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Insel Saint Barth\u00e9lemy<\/option><option value=\"Aland Inseln\"  class=\"choice-106 depth-1\"  >Aland Inseln<\/option><option value=\"Kaimaninseln\"  class=\"choice-107 depth-1\"  >Kaimaninseln<\/option><option value=\"Cocos (Keeling) Inseln\"  class=\"choice-108 depth-1\"  >Cocos (Keeling) Inseln<\/option><option value=\"Cookinseln\"  class=\"choice-109 depth-1\"  >Cookinseln<\/option><option value=\"Falklandinseln (Malwinen)\"  class=\"choice-110 depth-1\"  >Falklandinseln (Malwinen)<\/option><option value=\"F\u00e4r\u00f6er Inseln\"  class=\"choice-111 depth-1\"  >F\u00e4r\u00f6er Inseln<\/option><option value=\"Heard und McDonald Inseln\"  class=\"choice-112 depth-1\"  >Heard und McDonald Inseln<\/option><option value=\"N\u00f6rdliche Marianen\"  class=\"choice-113 depth-1\"  >N\u00f6rdliche Marianen<\/option><option value=\"Marshallinseln\"  class=\"choice-114 depth-1\"  >Marshallinseln<\/option><option value=\"Norfolkinseln\"  class=\"choice-115 depth-1\"  >Norfolkinseln<\/option><option value=\"Saint Pierre und Miquelon Inseln\"  class=\"choice-116 depth-1\"  >Saint Pierre und Miquelon Inseln<\/option><option value=\"Salomonen\"  class=\"choice-117 depth-1\"  >Salomonen<\/option><option value=\"Svalbard und Jan Mayen Inseln\"  class=\"choice-118 depth-1\"  >Svalbard und Jan Mayen Inseln<\/option><option value=\"Turks- und Caicosinseln\"  class=\"choice-119 depth-1\"  >Turks- und Caicosinseln<\/option><option value=\"Jungferninseln (US)\"  class=\"choice-120 depth-1\"  >Jungferninseln (US)<\/option><option value=\"Jungferninseln (Britisch)\"  class=\"choice-121 depth-1\"  >Jungferninseln (Britisch)<\/option><option value=\"United States Minor Outlying Islands\"  class=\"choice-122 depth-1\"  >United States Minor Outlying Islands<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italien\"  class=\"choice-124 depth-1\"  >Italien<\/option><option value=\"Kasachstan\"  class=\"choice-125 depth-1\"  >Kasachstan<\/option><option value=\"Kenia\"  class=\"choice-126 depth-1\"  >Kenia<\/option><option value=\"Kirgisistan\"  class=\"choice-127 depth-1\"  >Kirgisistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (Demokratische Volksrepublik)\"  class=\"choice-129 depth-1\"  >Korea (Demokratische Volksrepublik)<\/option><option value=\"Korea (Republik)\"  class=\"choice-130 depth-1\"  >Korea (Republik)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettland\"  class=\"choice-134 depth-1\"  >Lettland<\/option><option value=\"Libanon\"  class=\"choice-135 depth-1\"  >Libanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libyen\"  class=\"choice-137 depth-1\"  >Libyen<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Litauen\"  class=\"choice-139 depth-1\"  >Litauen<\/option><option value=\"Luxemburg\"  class=\"choice-140 depth-1\"  >Luxemburg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Nord-Mazedonien (Republik)\"  class=\"choice-142 depth-1\"  >Nord-Mazedonien (Republik)<\/option><option value=\"Madagaskar\"  class=\"choice-143 depth-1\"  >Madagaskar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Malediven\"  class=\"choice-146 depth-1\"  >Malediven<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Marokko\"  class=\"choice-150 depth-1\"  >Marokko<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauretanien\"  class=\"choice-152 depth-1\"  >Mauretanien<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexiko\"  class=\"choice-155 depth-1\"  >Mexiko<\/option><option value=\"Mikronesien (Konf\u00f6deration der Staaten von)\"  class=\"choice-156 depth-1\"  >Mikronesien (Konf\u00f6deration der Staaten von)<\/option><option value=\"Moldawien (Republik)\"  class=\"choice-157 depth-1\"  >Moldawien (Republik)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolei\"  class=\"choice-159 depth-1\"  >Mongolei<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mosambik\"  class=\"choice-162 depth-1\"  >Mosambik<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norwegen\"  class=\"choice-170 depth-1\"  >Norwegen<\/option><option value=\"Neukaledonien\"  class=\"choice-171 depth-1\"  >Neukaledonien<\/option><option value=\"Neuseeland\"  class=\"choice-172 depth-1\"  >Neuseeland<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Die Niederlande\"  class=\"choice-174 depth-1\"  >Die Niederlande<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Pal\u00e4stina (Staat)\"  class=\"choice-177 depth-1\"  >Pal\u00e4stina (Staat)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua-Neuguinea\"  class=\"choice-179 depth-1\"  >Papua-Neuguinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Polen\"  class=\"choice-183 depth-1\"  >Polen<\/option><option value=\"Franz\u00f6sisch-Polynesien\"  class=\"choice-184 depth-1\"  >Franz\u00f6sisch-Polynesien<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Katar\"  class=\"choice-187 depth-1\"  >Katar<\/option><option value=\"Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland\"  class=\"choice-188 depth-1\"  >Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland<\/option><option value=\"Arabische Republik Syrien\"  class=\"choice-189 depth-1\"  >Arabische Republik Syrien<\/option><option value=\"Tschechische Republik\"  class=\"choice-190 depth-1\"  >Tschechische Republik<\/option><option value=\"Zentralafrikanische Republik\"  class=\"choice-191 depth-1\"  >Zentralafrikanische Republik<\/option><option value=\"Demokratische Volksrepublik Laos\"  class=\"choice-192 depth-1\"  >Demokratische Volksrepublik Laos<\/option><option value=\"Dominikanische Republik\"  class=\"choice-193 depth-1\"  >Dominikanische Republik<\/option><option value=\"La R\u00e9union (Insel)\"  class=\"choice-194 depth-1\"  >La R\u00e9union (Insel)<\/option><option value=\"Rum\u00e4nien\"  class=\"choice-195 depth-1\"  >Rum\u00e4nien<\/option><option value=\"Ruanda\"  class=\"choice-196 depth-1\"  >Ruanda<\/option><option value=\"Westsahara\"  class=\"choice-197 depth-1\"  >Westsahara<\/option><option value=\"St. Kitts und Nevis\"  class=\"choice-198 depth-1\"  >St. Kitts und Nevis<\/option><option value=\"St. Vincent und die Grenadinen\"  class=\"choice-199 depth-1\"  >St. Vincent und die Grenadinen<\/option><option value=\"Saint-Martin (franz\u00f6sischer Teil)\"  class=\"choice-200 depth-1\"  >Saint-Martin (franz\u00f6sischer Teil)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Amerikanisch-Samoa\"  class=\"choice-202 depth-1\"  >Amerikanisch-Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension und Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension und Tristan da Cunha<\/option><option value=\"St. Lucia\"  class=\"choice-205 depth-1\"  >St. Lucia<\/option><option value=\"Sao Tome und Principe\"  class=\"choice-206 depth-1\"  >Sao Tome und Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbien\"  class=\"choice-208 depth-1\"  >Serbien<\/option><option value=\"Seychellen\"  class=\"choice-209 depth-1\"  >Seychellen<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapur\"  class=\"choice-211 depth-1\"  >Singapur<\/option><option value=\"Sint Maarten (Teil der Niederlande)\"  class=\"choice-212 depth-1\"  >Sint Maarten (Teil der Niederlande)<\/option><option value=\"Slowakei\"  class=\"choice-213 depth-1\"  >Slowakei<\/option><option value=\"Slowenien\"  class=\"choice-214 depth-1\"  >Slowenien<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spanien\"  class=\"choice-216 depth-1\"  >Spanien<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"Vereinigte Staaten von Amerika\"  class=\"choice-218 depth-1\"  >Vereinigte Staaten von Amerika<\/option><option value=\"Staat Vatikanstadt\"  class=\"choice-219 depth-1\"  >Staat Vatikanstadt<\/option><option value=\"S\u00fcdafrika\"  class=\"choice-220 depth-1\"  >S\u00fcdafrika<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"S\u00fcdsudan\"  class=\"choice-222 depth-1\"  >S\u00fcdsudan<\/option><option value=\"Surinam\"  class=\"choice-223 depth-1\"  >Surinam<\/option><option value=\"Schweden\"  class=\"choice-224 depth-1\"  >Schweden<\/option><option value=\"Schweiz\"  selected='selected' class=\"choice-225 depth-1\"  >Schweiz<\/option><option value=\"Tadschikistan\"  class=\"choice-226 depth-1\"  >Tadschikistan<\/option><option value=\"Taiwan, Republik China\"  class=\"choice-227 depth-1\"  >Taiwan, Republik China<\/option><option value=\"Tansania (Vereinigte Republik)\"  class=\"choice-228 depth-1\"  >Tansania (Vereinigte Republik)<\/option><option value=\"Franz\u00f6sische S\u00fcd-Territorien\"  class=\"choice-229 depth-1\"  >Franz\u00f6sische S\u00fcd-Territorien<\/option><option value=\"Britisches Territorium im Indischen Ozean\"  class=\"choice-230 depth-1\"  >Britisches Territorium im Indischen Ozean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"Osttimor\"  class=\"choice-232 depth-1\"  >Osttimor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad und Tobago\"  class=\"choice-236 depth-1\"  >Trinidad und Tobago<\/option><option value=\"Tunesien\"  class=\"choice-237 depth-1\"  >Tunesien<\/option><option value=\"T\u00fcrkei\"  class=\"choice-238 depth-1\"  >T\u00fcrkei<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Ungarn\"  class=\"choice-243 depth-1\"  >Ungarn<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Usbekistan\"  class=\"choice-245 depth-1\"  >Usbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivianische Republik)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivianische Republik)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis und Futuna\"  class=\"choice-249 depth-1\"  >Wallis und Futuna<\/option><option value=\"Jemen\"  class=\"choice-250 depth-1\"  >Jemen<\/option><option value=\"Sambia\"  class=\"choice-251 depth-1\"  >Sambia<\/option><option value=\"Simbabwe\"  class=\"choice-252 depth-1\"  >Simbabwe<\/option><option value=\"eSwatini (K\u00f6nigreich)\"  class=\"choice-253 depth-1\"  >eSwatini (K\u00f6nigreich)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_44-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_44\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_44\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][44][address1]\" placeholder=\"Adresse\" required><label for=\"wpforms-58-field_44\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse Zeile 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_44-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][44][city]\" placeholder=\"St\u00e4dte\" required><label for=\"wpforms-58-field_44-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Stadt<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_44-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][44][state]\" placeholder=\"Kanton\" required><label for=\"wpforms-58-field_44-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_45-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_45\">Telefon <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_45\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][45]\" placeholder=\"Telefon\" aria-label=\"Telefon\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_46-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_46\">E-Mail<\/label><input type=\"email\" id=\"wpforms-58-field_46\" class=\"wpforms-field-large\" name=\"wpforms[fields][46]\" placeholder=\"E-Mail\" spellcheck=\"false\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_48\">Behandelnder Arzt <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_48\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][48]\" placeholder=\"Behandelnder Arzt\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_95-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"95\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_96-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_96\">Versicherungsgesellschaft<\/label><input type=\"text\" id=\"wpforms-58-field_96\" class=\"wpforms-field-large\" name=\"wpforms[fields][96]\" placeholder=\"Versicherungsgesellschaft\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_97-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_97\">AVS<\/label><input type=\"text\" id=\"wpforms-58-field_97\" class=\"wpforms-field-large\" name=\"wpforms[fields][97]\" placeholder=\"AVS\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_49\">Versicherte Nummer<\/label><input type=\"text\" id=\"wpforms-58-field_49\" class=\"wpforms-field-large\" name=\"wpforms[fields][49]\" placeholder=\"Versicherte Nummer\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_89-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"89\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tGrund f\u00fcr die Kontaktaufnahme\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_90-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"90\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_90\">Hauptdiagnose <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_90\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][90]\" placeholder=\"Spezifische Hauptdiagnose\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_93-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"93\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_93\">Spezifische Nebendiagnosen  <\/label><input type=\"text\" id=\"wpforms-58-field_93\" class=\"wpforms-field-large\" name=\"wpforms[fields][93]\" placeholder=\"Grundlegende Nebendiagnosen\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_91-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"91\" style=\"display:none;\"><label class=\"wpforms-field-label\">Erforderliche Dienstleistungen <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_91\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_1\" name=\"wpforms[fields][91][]\" value=\"Grundlegende Pflegeleistungen\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_1\">Grundlegende Pflegeleistungen<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_2\" name=\"wpforms[fields][91][]\" value=\"Pflegedienste\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_2\">Pflegedienste<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_4\" name=\"wpforms[fields][91][]\" value=\"Spezialisierte Pflegedienste\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_4\">Spezialisierte Pflegedienste<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_7\" name=\"wpforms[fields][91][]\" value=\"Private Dienstleistungen\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_7\">Private Dienstleistungen<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_6\" name=\"wpforms[fields][91][]\" value=\"Internationale Leistung\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_6\">Internationale Leistung<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_9\" name=\"wpforms[fields][91][]\" value=\"Telemedizinischer Dienst\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_9\">Telemedizinischer Dienst<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_8\" name=\"wpforms[fields][91][]\" value=\"Telecare-Dienst\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_8\">Telecare-Dienst<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_94-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"94\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_94\">Anzahl der erforderlichen Interventionen<\/label><input type=\"text\" id=\"wpforms-58-field_94\" class=\"wpforms-field-large\" name=\"wpforms[fields][94]\" placeholder=\"Bestimmte Anzahl von Interventionen\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_92-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"92\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_92\">Aufforderung, die Verantwortung zu \u00fcbernehmen <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_92\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][92][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_74-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"74\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tGrad der Priorit\u00e4t\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_75-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"75\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">Mehrfachauswahl <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_75\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_1\" name=\"wpforms[fields][75]\" value=\"Niedrig\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_1\">Niedrig<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_2\" name=\"wpforms[fields][75]\" value=\"Medium\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_2\">Medium<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_3\" name=\"wpforms[fields][75]\" value=\"Hoch\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_3\">Hoch<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_4\" name=\"wpforms[fields][75]\" value=\"Anfrage nach ausf\u00fchrlichen Informationen \u00fcber den Service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_4\">Anfrage nach ausf\u00fchrlichen Informationen \u00fcber den Service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_76-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"76\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_76\">Zus\u00e4tzlicher Text<\/label><textarea id=\"wpforms-58-field_76\" class=\"wpforms-field-medium\" name=\"wpforms[fields][76]\" placeholder=\"Zus\u00e4tzlicher Text\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_73-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tAnfordernder behandelnder Arzt\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_66\">Anfordernder behandelnder Arzt <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_66\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][66]\" placeholder=\"Geben Sie den Namen des behandelnden Arztes an, der den Antrag gestellt hat\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_57-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"57\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPatientendaten\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"58\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_58\">vorname nachname <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_58\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][58]\" placeholder=\"Name und Nachname\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_59-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_59\">Geburtsdatum <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_59\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][59][date]\" placeholder=\"Geburtsdatum\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_109-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"109\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_109\">Land Patient<\/label><select id=\"wpforms-58-field_109\" class=\"wpforms-field-large\" name=\"wpforms[fields][109]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanien\"  class=\"choice-5 depth-1\"  >Albanien<\/option><option value=\"Algerien\"  class=\"choice-6 depth-1\"  >Algerien<\/option><option value=\"Andorra\"  class=\"choice-7 depth-1\"  >Andorra<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarktis\"  class=\"choice-10 depth-1\"  >Antarktis<\/option><option value=\"Antigua und Barbuda\"  class=\"choice-11 depth-1\"  >Antigua und Barbuda<\/option><option value=\"Saudi-Arabien\"  class=\"choice-12 depth-1\"  >Saudi-Arabien<\/option><option value=\"Argentinien\"  class=\"choice-13 depth-1\"  >Argentinien<\/option><option value=\"Armenien\"  class=\"choice-14 depth-1\"  >Armenien<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australien\"  class=\"choice-16 depth-1\"  >Australien<\/option><option value=\"\u00d6sterreich\"  class=\"choice-17 depth-1\"  >\u00d6sterreich<\/option><option value=\"Aserbaidschan\"  class=\"choice-18 depth-1\"  >Aserbaidschan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahrain\"  class=\"choice-20 depth-1\"  >Bahrain<\/option><option value=\"Bangladesch\"  class=\"choice-21 depth-1\"  >Bangladesch<\/option><option value=\"Barbados\"  class=\"choice-22 depth-1\"  >Barbados<\/option><option value=\"Belgien\"  class=\"choice-23 depth-1\"  >Belgien<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"Benin\"  class=\"choice-25 depth-1\"  >Benin<\/option><option value=\"Bermuda\"  class=\"choice-26 depth-1\"  >Bermuda<\/option><option value=\"Bhutan\"  class=\"choice-27 depth-1\"  >Bhutan<\/option><option value=\"Wei\u00dfrussland\"  class=\"choice-28 depth-1\"  >Wei\u00dfrussland<\/option><option value=\"Birma\"  class=\"choice-29 depth-1\"  >Birma<\/option><option value=\"Bolivien (Plurinationaler Staat)\"  class=\"choice-30 depth-1\"  >Bolivien (Plurinationaler Staat)<\/option><option value=\"Bonaire, St. Eustatius und Saba\"  class=\"choice-31 depth-1\"  >Bonaire, St. Eustatius und Saba<\/option><option value=\"Bosnien und Herzegowina\"  class=\"choice-32 depth-1\"  >Bosnien und Herzegowina<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Brasilien\"  class=\"choice-34 depth-1\"  >Brasilien<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarien\"  class=\"choice-36 depth-1\"  >Bulgarien<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Kambodscha\"  class=\"choice-39 depth-1\"  >Kambodscha<\/option><option value=\"Kamerun\"  class=\"choice-40 depth-1\"  >Kamerun<\/option><option value=\"Kanada\"  class=\"choice-41 depth-1\"  >Kanada<\/option><option value=\"Kap Verde\"  class=\"choice-42 depth-1\"  >Kap Verde<\/option><option value=\"Chad\"  class=\"choice-43 depth-1\"  >Chad<\/option><option value=\"Chile\"  class=\"choice-44 depth-1\"  >Chile<\/option><option value=\"China\"  class=\"choice-45 depth-1\"  >China<\/option><option value=\"Zypern\"  class=\"choice-46 depth-1\"  >Zypern<\/option><option value=\"Kolumbien\"  class=\"choice-47 depth-1\"  >Kolumbien<\/option><option value=\"Komoren\"  class=\"choice-48 depth-1\"  >Komoren<\/option><option value=\"Kongo\"  class=\"choice-49 depth-1\"  >Kongo<\/option><option value=\"Kongo (Demokratische Republik)\"  class=\"choice-50 depth-1\"  >Kongo (Demokratische Republik)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"Elfenbeink\u00fcste\"  class=\"choice-52 depth-1\"  >Elfenbeink\u00fcste<\/option><option value=\"Kroatien\"  class=\"choice-53 depth-1\"  >Kroatien<\/option><option value=\"Kuba\"  class=\"choice-54 depth-1\"  >Kuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"D\u00e4nemark\"  class=\"choice-56 depth-1\"  >D\u00e4nemark<\/option><option value=\"Dominica\"  class=\"choice-57 depth-1\"  >Dominica<\/option><option value=\"Ecuador\"  class=\"choice-58 depth-1\"  >Ecuador<\/option><option value=\"\u00c4gypten\"  class=\"choice-59 depth-1\"  >\u00c4gypten<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"Vereinigte Arabische Emirate\"  class=\"choice-61 depth-1\"  >Vereinigte Arabische Emirate<\/option><option value=\"Eritrea\"  class=\"choice-62 depth-1\"  >Eritrea<\/option><option value=\"Estland\"  class=\"choice-63 depth-1\"  >Estland<\/option><option value=\"\u00c4thiopien\"  class=\"choice-64 depth-1\"  >\u00c4thiopien<\/option><option value=\"Russische F\u00f6deration\"  class=\"choice-65 depth-1\"  >Russische F\u00f6deration<\/option><option value=\"Fidschi\"  class=\"choice-66 depth-1\"  >Fidschi<\/option><option value=\"Philippinen\"  class=\"choice-67 depth-1\"  >Philippinen<\/option><option value=\"Finnland\"  class=\"choice-68 depth-1\"  >Finnland<\/option><option value=\"Frankreich\"  class=\"choice-69 depth-1\"  >Frankreich<\/option><option value=\"Gabun\"  class=\"choice-70 depth-1\"  >Gabun<\/option><option value=\"Gambia\"  class=\"choice-71 depth-1\"  >Gambia<\/option><option value=\"Georgia\"  class=\"choice-72 depth-1\"  >Georgia<\/option><option value=\"S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln\"  class=\"choice-73 depth-1\"  >S\u00fcdgeorgien und die S\u00fcdlichen Sandwichinseln<\/option><option value=\"Deutschland\"  class=\"choice-74 depth-1\"  >Deutschland<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jamaika\"  class=\"choice-76 depth-1\"  >Jamaika<\/option><option value=\"Japan\"  class=\"choice-77 depth-1\"  >Japan<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Dschibuti\"  class=\"choice-79 depth-1\"  >Dschibuti<\/option><option value=\"Jordanien\"  class=\"choice-80 depth-1\"  >Jordanien<\/option><option value=\"Griechenland\"  class=\"choice-81 depth-1\"  >Griechenland<\/option><option value=\"Grenada\"  class=\"choice-82 depth-1\"  >Grenada<\/option><option value=\"Gr\u00f6nland\"  class=\"choice-83 depth-1\"  >Gr\u00f6nland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernsey\"  class=\"choice-87 depth-1\"  >Guernsey<\/option><option value=\"Franz\u00f6sisch-Guayana\"  class=\"choice-88 depth-1\"  >Franz\u00f6sisch-Guayana<\/option><option value=\"Guinea\"  class=\"choice-89 depth-1\"  >Guinea<\/option><option value=\"\u00c4quatorial-Guinea\"  class=\"choice-90 depth-1\"  >\u00c4quatorial-Guinea<\/option><option value=\"Guinea-Bissau\"  class=\"choice-91 depth-1\"  >Guinea-Bissau<\/option><option value=\"Guyana\"  class=\"choice-92 depth-1\"  >Guyana<\/option><option value=\"Haiti\"  class=\"choice-93 depth-1\"  >Haiti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hongkong\"  class=\"choice-95 depth-1\"  >Hongkong<\/option><option value=\"Indien\"  class=\"choice-96 depth-1\"  >Indien<\/option><option value=\"Indonesien\"  class=\"choice-97 depth-1\"  >Indonesien<\/option><option value=\"Iran (Islamische Republik)\"  class=\"choice-98 depth-1\"  >Iran (Islamische Republik)<\/option><option value=\"Irak\"  class=\"choice-99 depth-1\"  >Irak<\/option><option value=\"Irland (Republik)\"  class=\"choice-100 depth-1\"  >Irland (Republik)<\/option><option value=\"Island\"  class=\"choice-101 depth-1\"  >Island<\/option><option value=\"Bouvetinsel\"  class=\"choice-102 depth-1\"  >Bouvetinsel<\/option><option value=\"Isle of Man\"  class=\"choice-103 depth-1\"  >Isle of Man<\/option><option value=\"Weihnachtsinsel\"  class=\"choice-104 depth-1\"  >Weihnachtsinsel<\/option><option value=\"Insel Saint Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >Insel Saint Barth\u00e9lemy<\/option><option value=\"Aland Inseln\"  class=\"choice-106 depth-1\"  >Aland Inseln<\/option><option value=\"Kaimaninseln\"  class=\"choice-107 depth-1\"  >Kaimaninseln<\/option><option value=\"Cocos (Keeling) Inseln\"  class=\"choice-108 depth-1\"  >Cocos (Keeling) Inseln<\/option><option value=\"Cookinseln\"  class=\"choice-109 depth-1\"  >Cookinseln<\/option><option value=\"Falklandinseln (Malwinen)\"  class=\"choice-110 depth-1\"  >Falklandinseln (Malwinen)<\/option><option value=\"F\u00e4r\u00f6er Inseln\"  class=\"choice-111 depth-1\"  >F\u00e4r\u00f6er Inseln<\/option><option value=\"Heard und McDonald Inseln\"  class=\"choice-112 depth-1\"  >Heard und McDonald Inseln<\/option><option value=\"N\u00f6rdliche Marianen\"  class=\"choice-113 depth-1\"  >N\u00f6rdliche Marianen<\/option><option value=\"Marshallinseln\"  class=\"choice-114 depth-1\"  >Marshallinseln<\/option><option value=\"Norfolkinseln\"  class=\"choice-115 depth-1\"  >Norfolkinseln<\/option><option value=\"Saint Pierre und Miquelon Inseln\"  class=\"choice-116 depth-1\"  >Saint Pierre und Miquelon Inseln<\/option><option value=\"Salomonen\"  class=\"choice-117 depth-1\"  >Salomonen<\/option><option value=\"Svalbard und Jan Mayen Inseln\"  class=\"choice-118 depth-1\"  >Svalbard und Jan Mayen Inseln<\/option><option value=\"Turks- und Caicosinseln\"  class=\"choice-119 depth-1\"  >Turks- und Caicosinseln<\/option><option value=\"Jungferninseln (US)\"  class=\"choice-120 depth-1\"  >Jungferninseln (US)<\/option><option value=\"Jungferninseln (Britisch)\"  class=\"choice-121 depth-1\"  >Jungferninseln (Britisch)<\/option><option value=\"United States Minor Outlying Islands\"  class=\"choice-122 depth-1\"  >United States Minor Outlying Islands<\/option><option value=\"Israel\"  class=\"choice-123 depth-1\"  >Israel<\/option><option value=\"Italien\"  class=\"choice-124 depth-1\"  >Italien<\/option><option value=\"Kasachstan\"  class=\"choice-125 depth-1\"  >Kasachstan<\/option><option value=\"Kenia\"  class=\"choice-126 depth-1\"  >Kenia<\/option><option value=\"Kirgisistan\"  class=\"choice-127 depth-1\"  >Kirgisistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Korea (Demokratische Volksrepublik)\"  class=\"choice-129 depth-1\"  >Korea (Demokratische Volksrepublik)<\/option><option value=\"Korea (Republik)\"  class=\"choice-130 depth-1\"  >Korea (Republik)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kuwait\"  class=\"choice-132 depth-1\"  >Kuwait<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettland\"  class=\"choice-134 depth-1\"  >Lettland<\/option><option value=\"Libanon\"  class=\"choice-135 depth-1\"  >Libanon<\/option><option value=\"Liberia\"  class=\"choice-136 depth-1\"  >Liberia<\/option><option value=\"Libyen\"  class=\"choice-137 depth-1\"  >Libyen<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Litauen\"  class=\"choice-139 depth-1\"  >Litauen<\/option><option value=\"Luxemburg\"  class=\"choice-140 depth-1\"  >Luxemburg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Nord-Mazedonien (Republik)\"  class=\"choice-142 depth-1\"  >Nord-Mazedonien (Republik)<\/option><option value=\"Madagaskar\"  class=\"choice-143 depth-1\"  >Madagaskar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Malediven\"  class=\"choice-146 depth-1\"  >Malediven<\/option><option value=\"Malaysia\"  class=\"choice-147 depth-1\"  >Malaysia<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malta\"  class=\"choice-149 depth-1\"  >Malta<\/option><option value=\"Marokko\"  class=\"choice-150 depth-1\"  >Marokko<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauretanien\"  class=\"choice-152 depth-1\"  >Mauretanien<\/option><option value=\"Mauritius\"  class=\"choice-153 depth-1\"  >Mauritius<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexiko\"  class=\"choice-155 depth-1\"  >Mexiko<\/option><option value=\"Mikronesien (Konf\u00f6deration der Staaten von)\"  class=\"choice-156 depth-1\"  >Mikronesien (Konf\u00f6deration der Staaten von)<\/option><option value=\"Moldawien (Republik)\"  class=\"choice-157 depth-1\"  >Moldawien (Republik)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolei\"  class=\"choice-159 depth-1\"  >Mongolei<\/option><option value=\"Montenegro\"  class=\"choice-160 depth-1\"  >Montenegro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mosambik\"  class=\"choice-162 depth-1\"  >Mosambik<\/option><option value=\"Namibia\"  class=\"choice-163 depth-1\"  >Namibia<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"Nepal\"  class=\"choice-165 depth-1\"  >Nepal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nigeria\"  class=\"choice-168 depth-1\"  >Nigeria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norwegen\"  class=\"choice-170 depth-1\"  >Norwegen<\/option><option value=\"Neukaledonien\"  class=\"choice-171 depth-1\"  >Neukaledonien<\/option><option value=\"Neuseeland\"  class=\"choice-172 depth-1\"  >Neuseeland<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Die Niederlande\"  class=\"choice-174 depth-1\"  >Die Niederlande<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Pal\u00e4stina (Staat)\"  class=\"choice-177 depth-1\"  >Pal\u00e4stina (Staat)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papua-Neuguinea\"  class=\"choice-179 depth-1\"  >Papua-Neuguinea<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"Peru\"  class=\"choice-181 depth-1\"  >Peru<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Polen\"  class=\"choice-183 depth-1\"  >Polen<\/option><option value=\"Franz\u00f6sisch-Polynesien\"  class=\"choice-184 depth-1\"  >Franz\u00f6sisch-Polynesien<\/option><option value=\"Puerto Rico\"  class=\"choice-185 depth-1\"  >Puerto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Katar\"  class=\"choice-187 depth-1\"  >Katar<\/option><option value=\"Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland\"  class=\"choice-188 depth-1\"  >Vereinigtes K\u00f6nigreich von Gro\u00dfbritannien und Nordirland<\/option><option value=\"Arabische Republik Syrien\"  class=\"choice-189 depth-1\"  >Arabische Republik Syrien<\/option><option value=\"Tschechische Republik\"  class=\"choice-190 depth-1\"  >Tschechische Republik<\/option><option value=\"Zentralafrikanische Republik\"  class=\"choice-191 depth-1\"  >Zentralafrikanische Republik<\/option><option value=\"Demokratische Volksrepublik Laos\"  class=\"choice-192 depth-1\"  >Demokratische Volksrepublik Laos<\/option><option value=\"Dominikanische Republik\"  class=\"choice-193 depth-1\"  >Dominikanische Republik<\/option><option value=\"La R\u00e9union (Insel)\"  class=\"choice-194 depth-1\"  >La R\u00e9union (Insel)<\/option><option value=\"Rum\u00e4nien\"  class=\"choice-195 depth-1\"  >Rum\u00e4nien<\/option><option value=\"Ruanda\"  class=\"choice-196 depth-1\"  >Ruanda<\/option><option value=\"Westsahara\"  class=\"choice-197 depth-1\"  >Westsahara<\/option><option value=\"St. Kitts und Nevis\"  class=\"choice-198 depth-1\"  >St. Kitts und Nevis<\/option><option value=\"St. Vincent und die Grenadinen\"  class=\"choice-199 depth-1\"  >St. Vincent und die Grenadinen<\/option><option value=\"Saint-Martin (franz\u00f6sischer Teil)\"  class=\"choice-200 depth-1\"  >Saint-Martin (franz\u00f6sischer Teil)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Amerikanisch-Samoa\"  class=\"choice-202 depth-1\"  >Amerikanisch-Samoa<\/option><option value=\"San Marino\"  class=\"choice-203 depth-1\"  >San Marino<\/option><option value=\"St. Helena, Ascension und Tristan da Cunha\"  class=\"choice-204 depth-1\"  >St. Helena, Ascension und Tristan da Cunha<\/option><option value=\"St. Lucia\"  class=\"choice-205 depth-1\"  >St. Lucia<\/option><option value=\"Sao Tome und Principe\"  class=\"choice-206 depth-1\"  >Sao Tome und Principe<\/option><option value=\"Senegal\"  class=\"choice-207 depth-1\"  >Senegal<\/option><option value=\"Serbien\"  class=\"choice-208 depth-1\"  >Serbien<\/option><option value=\"Seychellen\"  class=\"choice-209 depth-1\"  >Seychellen<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapur\"  class=\"choice-211 depth-1\"  >Singapur<\/option><option value=\"Sint Maarten (Teil der Niederlande)\"  class=\"choice-212 depth-1\"  >Sint Maarten (Teil der Niederlande)<\/option><option value=\"Slowakei\"  class=\"choice-213 depth-1\"  >Slowakei<\/option><option value=\"Slowenien\"  class=\"choice-214 depth-1\"  >Slowenien<\/option><option value=\"Somalia\"  class=\"choice-215 depth-1\"  >Somalia<\/option><option value=\"Spanien\"  class=\"choice-216 depth-1\"  >Spanien<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"Vereinigte Staaten von Amerika\"  class=\"choice-218 depth-1\"  >Vereinigte Staaten von Amerika<\/option><option value=\"Staat Vatikanstadt\"  class=\"choice-219 depth-1\"  >Staat Vatikanstadt<\/option><option value=\"S\u00fcdafrika\"  class=\"choice-220 depth-1\"  >S\u00fcdafrika<\/option><option value=\"Sudan\"  class=\"choice-221 depth-1\"  >Sudan<\/option><option value=\"S\u00fcdsudan\"  class=\"choice-222 depth-1\"  >S\u00fcdsudan<\/option><option value=\"Surinam\"  class=\"choice-223 depth-1\"  >Surinam<\/option><option value=\"Schweden\"  class=\"choice-224 depth-1\"  >Schweden<\/option><option value=\"Schweiz\"  selected='selected' class=\"choice-225 depth-1\"  >Schweiz<\/option><option value=\"Tadschikistan\"  class=\"choice-226 depth-1\"  >Tadschikistan<\/option><option value=\"Taiwan, Republik China\"  class=\"choice-227 depth-1\"  >Taiwan, Republik China<\/option><option value=\"Tansania (Vereinigte Republik)\"  class=\"choice-228 depth-1\"  >Tansania (Vereinigte Republik)<\/option><option value=\"Franz\u00f6sische S\u00fcd-Territorien\"  class=\"choice-229 depth-1\"  >Franz\u00f6sische S\u00fcd-Territorien<\/option><option value=\"Britisches Territorium im Indischen Ozean\"  class=\"choice-230 depth-1\"  >Britisches Territorium im Indischen Ozean<\/option><option value=\"Thailand\"  class=\"choice-231 depth-1\"  >Thailand<\/option><option value=\"Osttimor\"  class=\"choice-232 depth-1\"  >Osttimor<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinidad und Tobago\"  class=\"choice-236 depth-1\"  >Trinidad und Tobago<\/option><option value=\"Tunesien\"  class=\"choice-237 depth-1\"  >Tunesien<\/option><option value=\"T\u00fcrkei\"  class=\"choice-238 depth-1\"  >T\u00fcrkei<\/option><option value=\"Turkmenistan\"  class=\"choice-239 depth-1\"  >Turkmenistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Uganda\"  class=\"choice-242 depth-1\"  >Uganda<\/option><option value=\"Ungarn\"  class=\"choice-243 depth-1\"  >Ungarn<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Usbekistan\"  class=\"choice-245 depth-1\"  >Usbekistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (Bollivianische Republik)\"  class=\"choice-247 depth-1\"  >Venezuela (Bollivianische Republik)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis und Futuna\"  class=\"choice-249 depth-1\"  >Wallis und Futuna<\/option><option value=\"Jemen\"  class=\"choice-250 depth-1\"  >Jemen<\/option><option value=\"Sambia\"  class=\"choice-251 depth-1\"  >Sambia<\/option><option value=\"Simbabwe\"  class=\"choice-252 depth-1\"  >Simbabwe<\/option><option value=\"eSwatini (K\u00f6nigreich)\"  class=\"choice-253 depth-1\"  >eSwatini (K\u00f6nigreich)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_60-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"60\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_60\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_60\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][60][address1]\" placeholder=\"Adresse\" required><label for=\"wpforms-58-field_60\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse Zeile 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_60-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][60][city]\" placeholder=\"St\u00e4dte\" required><label for=\"wpforms-58-field_60-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Stadt<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_60-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][60][state]\" placeholder=\"Kanton\" required><label for=\"wpforms-58-field_60-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Region<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_61-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"61\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_61\">Telefon <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_61\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][61]\" placeholder=\"Telefon\" aria-label=\"Telefon\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_62-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_62\">E-Mail<\/label><input type=\"email\" id=\"wpforms-58-field_62\" class=\"wpforms-field-large\" name=\"wpforms[fields][62]\" placeholder=\"E-Mail\" spellcheck=\"false\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_63-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_63\">Kontaktperson und jeweilige Funktion <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-58-field_63\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][63]\" placeholder=\"Kontaktperson und deren Funktion (Einf\u00fcgen: Vor- und Nachname, Beziehung zum Patienten)\" required><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_100-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"100\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_101-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"101\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_101\">Versicherungsgesellschaft<\/label><input type=\"text\" id=\"wpforms-58-field_101\" class=\"wpforms-field-large\" name=\"wpforms[fields][101]\" placeholder=\"Versicherungsgesellschaft\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_102-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"102\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_102\">AVS<\/label><input type=\"text\" id=\"wpforms-58-field_102\" class=\"wpforms-field-large\" name=\"wpforms[fields][102]\" placeholder=\"AVS\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_103-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_103\">Versicherte Nummer<\/label><input type=\"text\" id=\"wpforms-58-field_103\" class=\"wpforms-field-large\" name=\"wpforms[fields][103]\" placeholder=\"Versicherte Nummer\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_67-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"67\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tGrund f\u00fcr die Kontaktaufnahme\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_68-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_68\">Hauptdiagnose <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_68\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][68]\" placeholder=\"Spezifische Hauptdiagnose\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"71\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_71\">Spezifische Nebendiagnosen   <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_71\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][71]\" placeholder=\"Grundlegende Nebendiagnosen\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_82-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"82\" style=\"display:none;\"><label class=\"wpforms-field-label\">Erforderliche Dienstleistungen <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_82\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_1\" name=\"wpforms[fields][82][]\" value=\"Grundlegende Pflegeleistungen\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_1\">Grundlegende Pflegeleistungen<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_2\" name=\"wpforms[fields][82][]\" value=\"Pflegedienste\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_2\">Pflegedienste<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_4\" name=\"wpforms[fields][82][]\" value=\"Spezialisierte Pflegedienste\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_4\">Spezialisierte Pflegedienste<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_7\" name=\"wpforms[fields][82][]\" value=\"Private Dienstleistungen\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_7\">Private Dienstleistungen<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_6\" name=\"wpforms[fields][82][]\" value=\"Internationale Leistung\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_6\">Internationale Leistung<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_9\" name=\"wpforms[fields][82][]\" value=\"Telemedizinischer Dienst\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_9\">Telemedizinischer Dienst<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_8\" name=\"wpforms[fields][82][]\" value=\"Telecare-Dienst\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_8\">Telecare-Dienst<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_72-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"72\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_72\">Anzahl der erforderlichen Interventionen <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_72\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][72]\" placeholder=\"Bestimmte Anzahl von Interventionen\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_70-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_70\">Aufforderung, die Verantwortung zu \u00fcbernehmen <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_70\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][70][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_77-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"77\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tGrad der Priorit\u00e4t\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_78-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"78\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">Mehrfachauswahl <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_1\" name=\"wpforms[fields][78]\" value=\"Niedrig\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_1\">Niedrig<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_2\" name=\"wpforms[fields][78]\" value=\"Medium\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_2\">Medium<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_3\" name=\"wpforms[fields][78]\" value=\"Hoch\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_3\">Hoch<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_4\" name=\"wpforms[fields][78]\" value=\"Anfrage nach ausf\u00fchrlichen Informationen \u00fcber den Service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_4\">Anfrage nach ausf\u00fchrlichen Informationen \u00fcber den Service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_79-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"79\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_79\">Zus\u00e4tzlicher Text<\/label><textarea id=\"wpforms-58-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" placeholder=\"Zus\u00e4tzlicher Text\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_8-container\" class=\"wpforms-field wpforms-field-gdpr-checkbox flagPrivacy wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"8\"><label class=\"wpforms-field-label wpforms-label-hide\">Zustimmung zum Datenschutz <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_8\" 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