{"id":1372,"date":"2021-10-23T07:54:36","date_gmt":"2021-10-23T10:54:36","guid":{"rendered":"https:\/\/www.netrisk.com.tr\/en\/?page_id=1372"},"modified":"2025-01-08T09:03:41","modified_gmt":"2025-01-08T12:03:41","slug":"appointment-request-form","status":"publish","type":"page","link":"https:\/\/www.netrisk.com.tr\/en\/?page_id=1372","title":{"rendered":"Appointment Request Form"},"content":{"rendered":"\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1387-o1\" lang=\"en\" dir=\"ltr\" data-wpcf7-id=\"1387\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1372#wpcf7-f1387-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1387\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1387-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p>Name and Lastname\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fullname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter your full name\" value=\"\" type=\"text\" name=\"fullname\" \/><\/span>\n<\/p>\n<p>Requested Service\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"service\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"service\"><option value=\"Please Select...\">Please Select...<\/option><option value=\"Dental Care\">Dental Care<\/option><option value=\"Psychological Support\">Psychological Support<\/option><option value=\"Dietitian\">Dietitian<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n<\/p>\n<p>GSM Phone Number\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gsm_number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter your phone number\" value=\"\" type=\"tel\" name=\"gsm_number\" \/><\/span>\n<\/p>\n<p>Your eMail Address\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"user_email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter your email address\" value=\"\" type=\"email\" name=\"user_email\" \/><\/span>\n<\/p>\n<p>Insurance Company\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"insurance_company\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Enter your insurance company\" value=\"\" type=\"text\" name=\"insurance_company\" \/><\/span>\n<\/p>\n<p>Identity or Insurance No\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"identity\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Enter your ID or Insurance No\" value=\"\" type=\"text\" name=\"identity\" \/><\/span>\n<\/p>\n<p>Please select location for requested service;\n<\/p>\n<p>City: <span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"city\"><option value=\"Please Select...\">Please Select...<\/option><option value=\"Adana\">Adana<\/option><option value=\"Istanbul\">Istanbul<\/option><option value=\"Ankara\">Ankara<\/option><\/select><\/span>\n<\/p>\n<p>District: <span class=\"wpcf7-form-control-wrap\" data-name=\"district\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Enter your district\" value=\"\" type=\"text\" name=\"district\" \/><\/span>\n<\/p>\n<p>Please select preferred date and time for requested service:\n<\/p>\n<p>1. <span class=\"wpcf7-form-control-wrap\" data-name=\"date1\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date1\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"time1\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"time1\"><option value=\"Not matters\">Not matters<\/option><option value=\"Morning\">Morning<\/option><option value=\"Afternoon\">Afternoon<\/option><\/select><\/span>\n<\/p>\n<p>2. <span class=\"wpcf7-form-control-wrap\" data-name=\"date2\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date2\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"time2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"time2\"><option value=\"Not matters\">Not matters<\/option><option value=\"Morning\">Morning<\/option><option value=\"Afternoon\">Afternoon<\/option><\/select><\/span>\n<\/p>\n<p>Please select your preferred channel for feedback and notifications:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"channel\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"channel\" value=\"SMS\" \/><span class=\"wpcf7-list-item-label\">SMS<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"channel\" value=\"eMail\" \/><span class=\"wpcf7-list-item-label\">eMail<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"channel\" value=\"Not matters\" \/><span class=\"wpcf7-list-item-label\">Not matters<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Please select your preferred channel for service quality surveys:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"survey\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"survey\" value=\"SMS\" \/><span class=\"wpcf7-list-item-label\">SMS<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"survey\" value=\"eMail\" \/><span class=\"wpcf7-list-item-label\">eMail<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"survey\" value=\"Not matters\" \/><span class=\"wpcf7-list-item-label\">Not matters<\/span><\/span><\/span><\/span>\n<\/p>\n<p><input type=\"hidden\" name=\"_wpcf7_captcha_challenge_new-captcha\" value=\"1037587956\" \/><img decoding=\"async\" class=\"wpcf7-form-control wpcf7-captchac wpcf7-captcha-new-captcha\" width=\"72\" height=\"24\" alt=\"captcha\" src=\"https:\/\/www.netrisk.com.tr\/en\/wp-content\/uploads\/wpcf7_captcha\/1037587956.png\" \/><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"new-captcha\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-captchar\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"new-captcha\" \/><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"234\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":10,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-templates\/full-width-container.php","meta":{"footnotes":""},"class_list":["post-1372","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=\/wp\/v2\/pages\/1372","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1372"}],"version-history":[{"count":8,"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=\/wp\/v2\/pages\/1372\/revisions"}],"predecessor-version":[{"id":1388,"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=\/wp\/v2\/pages\/1372\/revisions\/1388"}],"up":[{"embeddable":true,"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=\/wp\/v2\/pages\/10"}],"wp:attachment":[{"href":"https:\/\/www.netrisk.com.tr\/en\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1372"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}