{"id":11542,"date":"2015-11-20T17:07:36","date_gmt":"2015-11-20T16:07:36","guid":{"rendered":"http:\/\/www.dalpasso.it\/de\/?page_id=11542"},"modified":"2015-11-20T17:17:44","modified_gmt":"2015-11-20T16:17:44","slug":"formular-fuer-volljaehrige-patienten","status":"publish","type":"page","link":"https:\/\/www.dalpasso.it\/de\/kontakt\/zur-anforderung-ihrer-bilder\/formular-fuer-volljaehrige-patienten\/","title":{"rendered":"Formular f\u00fcr vollj\u00e4hrige Patienten"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row][vc_column width=&#8220;5\/6&#8243; css=&#8220;.vc_custom_1442915850638{padding: 20px !important;background-color: #b8e3f2 !important;}&#8220; offset=&#8220;vc_col-lg-7 vc_col-md-offset-2 vc_col-md-8 vc_col-sm-offset-1&#8243;][vc_column_text]<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f11544-o1\" lang=\"it-IT\" dir=\"ltr\" data-wpcf7-id=\"11544\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/de\/wp-json\/wp\/v2\/pages\/11542#wpcf7-f11544-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Modulo di contatto\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"11544\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"it_IT\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f11544-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p>Der Unterzeichnende *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nome\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nome\" \/><\/span>\n<\/p>\n<p>Geboren in *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"citta\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"citta\" \/><\/span>\n<\/p>\n<p>am (tt\/mm\/jjjj) *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"datanascita\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"datanascita\" \/><\/span>\n<\/p>\n<p>Wohnhaft in *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"residenza\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"residenza\" \/><\/span>\n<\/p>\n<p>Anschrift *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"indirizzo\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"indirizzo\" \/><\/span>\n<\/p>\n<p>E-mail*\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"e-mail\"><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\" value=\"\" type=\"email\" name=\"e-mail\" \/><\/span>\n<\/p>\n<hr \/>\n<h4>ERKL\u00c4RT HIERMIT\n<\/h4>\n<ul>\n\t<li>\n\t\t<p>-\tTr\u00e4ger einer Augenprothese zu sein, die von der Firma Dalpasso S.r.l. mit Sitz in Reggio Emilia, Via Turri 10, angepasst wurde *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro1\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">JA<\/span><input type=\"checkbox\" name=\"dichiaro1\" value=\"JA\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NEIN<\/span><input type=\"checkbox\" name=\"dichiaro1\" value=\"NEIN\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>-\tdass die Sanktionen f\u00fcr die Angabe falscher Daten oder Personalien bekannt sind *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro2\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">JA<\/span><input type=\"checkbox\" name=\"dichiaro2\" value=\"JA\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NEIN<\/span><input type=\"checkbox\" name=\"dichiaro2\" value=\"NEIN\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>von Dalpasso S.r.l. \u00fcber die Normen f\u00fcr die Bearbeitung sensibler Daten gem\u00e4\u00df ital. Gesetzesverordnung 196\/2003* informiert worden zu sein *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro3\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">JA<\/span><input type=\"checkbox\" name=\"dichiaro3\" value=\"JA\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NEIN<\/span><input type=\"checkbox\" name=\"dichiaro3\" value=\"NEIN\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>-\tHiermit wird Dalpasso S.r.l. von jeglicher Verantwortung bez\u00fcglich dieses Antrags freigestellt*\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro4\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">JA<\/span><input type=\"checkbox\" name=\"dichiaro4\" value=\"JA\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NEIN<\/span><input type=\"checkbox\" name=\"dichiaro4\" value=\"NEIN\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n<\/ul>\n<hr \/>\n<h4>HIERMIT WIRD BEANTRAGT\n<\/h4>\n<p>Die Zusendung einer Kopie der digitalen Fotografien, die bei der Firma Dalpasso s.r.l. aufgenommen und in deren Archiv gespeichert worden sind.\n<\/p>\n<p style=\"margin-top:0.5em;\">Datum der Aufnahmen: *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"descrizionefoto\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"descrizionefoto\"><\/textarea><\/span>\n<\/p>\n<p>Zu diesem Zweck wird folgender Datentr\u00e4ger f\u00fcr die angeforderten Bilder gew\u00e4hlt:\n<\/p>\n<ul>\n\t<li>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invio\"><span class=\"wpcf7-form-control wpcf7-checkbox inline\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"invio[]\" value=\"\" \/><span class=\"wpcf7-list-item-label\"><\/span><\/span><\/span><\/span> -\tCD Rom zum unfreien Versand auf dem Postweg *\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>-\tVersendung per E-Mail an folgende E-Mail-Adresse: *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invio_email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"invio_email\" \/><\/span>\n\t\t<\/p>\n\t<\/li>\n<\/ul>\n<p>Es wird umgehend die Fotokopie eines Personalausweises des Antragstellers zugesandt per: *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invio_documento\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Fax<\/span><input type=\"checkbox\" name=\"invio_documento\" value=\"Fax\" \/><\/label><\/span><span class=\"wpcf7-list-item\"><label><span class=\"wpcf7-list-item-label\">E-mail<\/span><input type=\"checkbox\" name=\"invio_documento\" value=\"E-mail\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Post<\/span><input type=\"checkbox\" name=\"invio_documento\" value=\"Post\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<hr \/>\n<h4>DATENSCHUTZ\n<\/h4>\n<p><small>Der Unterzeichnende nimmt die gem\u00e4\u00df Art. 13 der ital. Gesetzesverordnung 196\/2003 erteilte Datenschutzinformation zur Kenntnis und willigt hiermit in die Bearbeitung seiner personenbezogenen Daten f\u00fcr die angegebenen Zwecke sowie in deren Weiterleitung an Dritte f\u00fcr die erkl\u00e4rten Zwecke ein.<\/small>\n<\/p>\n<p><label>Einwilligung: <span class=\"wpcf7-form-control-wrap\" data-name=\"consenso\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"consenso\" value=\"1\" aria-invalid=\"false\" \/><\/span><\/span><\/span><\/label>\n<\/p>\n<div style=\"margin:1.5em 0\">\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Senden\" \/>\n\t<\/p>\n<\/div><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<p>[\/vc_column_text][\/vc_column][\/vc_row]<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column width=&#8220;5\/6&#8243; 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