{"id":4934,"date":"2015-07-22T15:17:54","date_gmt":"2015-07-22T13:17:54","guid":{"rendered":"http:\/\/www.dalpasso.it\/modulo-per-pazienti-maggiorenni-2\/"},"modified":"2015-11-13T11:39:33","modified_gmt":"2015-11-13T10:39:33","slug":"form-for-adults","status":"publish","type":"page","link":"https:\/\/www.dalpasso.it\/en\/contacts\/to-ask-for-your-images\/form-for-adults\/","title":{"rendered":"Form for adults"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row][vc_column width=&#8221;1\/4&#8243;]<br \/>\n[\/vc_column][vc_column width=&#8221;1\/2&#8243; css=&#8221;.vc_custom_1447411173414{padding-top: 20px !important;padding-right: 20px !important;padding-bottom: 20px !important;padding-left: 20px !important;background-color: #b8e3f2 !important;}&#8221;][vc_column_text]<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4931-o1\" lang=\"it-IT\" dir=\"ltr\" data-wpcf7-id=\"4931\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/4934#wpcf7-f4931-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=\"4931\" \/><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-f4931-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p>The undersigned *\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>DOB *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"citt\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"citt\" \/><\/span>\n<\/p>\n<p>(dd\/mm\/yyyy) *\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>Resident in*\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rezidenza\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rezidenza\" \/><\/span>\n<\/p>\n<p>Address *\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>DECLARES\n<\/h4>\n<p>that they wear an ocular prosthesis applied by Dalpasso s.r.l. with registered office in Reggio Emilia, via Turri n. 10 *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">YES<\/span><input type=\"checkbox\" name=\"dichiaro[]\" value=\"YES\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NO<\/span><input type=\"checkbox\" name=\"dichiaro[]\" value=\"NO\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<p>that they are aware of the legal consequences of providing false data or information *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">YES<\/span><input type=\"checkbox\" name=\"dichiaro2[]\" value=\"YES\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NO<\/span><input type=\"checkbox\" name=\"dichiaro2[]\" value=\"NO\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<p>that they have been informed by Dalpasso s.r.l. regarding the standards that govern the processing of sensitive data pursuant to Legislative Decree 196\/2003 *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">YES<\/span><input type=\"checkbox\" name=\"dichiaro3[]\" value=\"YES\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NO<\/span><input type=\"checkbox\" name=\"dichiaro3[]\" value=\"NO\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<p>holding harmless Dalpasso s.r.l. from all responsibility in relation to this request*\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">YES<\/span><input type=\"checkbox\" name=\"dichiaro4[]\" value=\"YES\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NO<\/span><input type=\"checkbox\" name=\"dichiaro4[]\" value=\"NO\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<hr \/>\n<h4>REQUESTS\n<\/h4>\n<p>a copy of the photographic digital images taken and stored in the magnetic archives of the company Dalpasso s.r.l. to be sent to them.\n<\/p>\n<p>date on which photographs were taken *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"descrizionedelfoto\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"descrizionedelfoto\"><\/textarea><\/span>\n<\/p>\n<p> For that purpose chooses the following support for the requested images:<br \/>\nCD Rom to be sent by post with costs charged to the addressee * <span class=\"wpcf7-form-control-wrap\" data-name=\"acceptanc\"><span class=\"wpcf7-form-control wpcf7-acceptance invert\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"acceptanc\" value=\"1\" aria-invalid=\"false\" \/><\/span><\/span><\/span>\n<\/p>\n<p> Email to be sent to the following address: *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invitocd\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"invitocd\" \/><\/span>\n<\/p>\n<p>I will provide a photocopy of a form of identification as soon as possible via: *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-658\"><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=\"checkbox-658\" value=\"Fax\" \/><\/label><\/span><span class=\"wpcf7-list-item\"><label><span class=\"wpcf7-list-item-label\">E-mail<\/span><input type=\"checkbox\" name=\"checkbox-658\" value=\"E-mail\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Servizio postale<\/span><input type=\"checkbox\" name=\"checkbox-658\" value=\"Servizio postale\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<hr \/>\n<h4>PRIVACY\n<\/h4>\n<p><br \/>\nThe undersigned acknowledges the information notice provided pursuant to Art. 13 of Legislative Decree 196\/2003 and provides consent for their personal data to be processed for the aims indicated and to be subject to communication to the parties and for the purposes stated.<br \/>\n<label>I ACCEPT <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<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"SEND A MESSAGE\" \/>\n<\/p><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_column width=&#8221;1\/4&#8243;]<br \/>\n[\/vc_column][\/vc_row]<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column width=&#8221;1\/4&#8243;] [\/vc_column][vc_column width=&#8221;1\/2&#8243; css=&#8221;.vc_custom_1447411173414{padding-top: 20px !important;padding-right: 20px !important;padding-bottom: 20px !important;padding-left: 20px !important;background-color: #b8e3f2 !important;}&#8221;][vc_column_text] [\/vc_column_text][\/vc_column][vc_column width=&#8221;1\/4&#8243;] [\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":4,"featured_media":0,"parent":3698,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-4934","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.1.1 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Form for adults | Dalpasso protesi oculari<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, 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