{"id":22,"date":"2026-02-04T09:42:38","date_gmt":"2026-02-04T09:42:38","guid":{"rendered":"https:\/\/socialetandarts.nl\/amstelveen\/?page_id=22"},"modified":"2026-02-19T08:43:39","modified_gmt":"2026-02-19T08:43:39","slug":"aanmelden","status":"publish","type":"page","link":"https:\/\/socialetandarts.nl\/amstelveen\/aanmelden\/","title":{"rendered":"Aanmelden"},"content":{"rendered":"\n<div class=\"inherit-container-width wp-block-group alignfull has-background is-layout-constrained wp-block-group-is-layout-constrained\" style=\"background-color:#cb063e\"><div class=\"wp-block-group__inner-container\">\n<div class=\"wp-block-media-text alignwide has-media-on-the-right is-stacked-on-mobile has-background\" style=\"background-color:#cb063e;grid-template-columns:auto 20%\"><div class=\"wp-block-media-text__content\">\n<h3 class=\"wp-block-heading has-ast-global-color-5-color has-text-color\" style=\"font-size:50px\">Aanmelden voor mondzorg<\/h3>\n\n\n\n<p><\/p>\n<\/div><figure class=\"wp-block-media-text__media\"><img decoding=\"async\" src=\"https:\/\/socialetandarts.nl\/rotterdam\/wp-content\/uploads\/sites\/2\/2021\/11\/tempd.png\" alt=\"\" class=\"wp-image-18 size-full\" \/><\/figure><\/div>\n<\/div><\/div>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center has-text-color\" style=\"color:#cb063e\">Aanmelden<\/h2>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-28f84493 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><script>\nvar 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class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Voor- en Achternaam<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Geboortedatum<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Geslacht<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_28'>\n\t\t\t<div class='gchoice gchoice_1_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Man'  id='choice_1_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_0' id='label_1_28_0' class='gform-field-label gform-field-label--type-inline'>Man<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Vrouw'  id='choice_1_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_1' id='label_1_28_1' class='gform-field-label gform-field-label--type-inline'>Vrouw<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_28_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='X'  id='choice_1_28_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_28_2' id='label_1_28_2' class='gform-field-label gform-field-label--type-inline'>X<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_7'>Adres: straat \/ huisnummer \/ postcode \/ woonplaats<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Telefoonnummer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>E-mailadres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Heeft u een hulpverlener? (Een hulpverlener is bijvoorbeeld een wijkteam-medewerker, begeleider, bewindvoerder, schulphulpmaatje etc)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_10'>\n\t\t\t<div class='gchoice gchoice_1_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Ja'  id='choice_1_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_10_0' id='label_1_10_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Nee'  id='choice_1_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_10_1' id='label_1_10_1' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Naam Hulpverlener<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>E-mail en telefoonnummer hulpverlener<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Hoe zou u in het algemeen de gezondheid van uw tanden en tandvlees omschrijven?<\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_1_12' class='large gfield_select'     aria-invalid=\"false\" ><option value='Zeer goed' >Zeer goed<\/option><option value='Goed' >Goed<\/option><option value='Gaat wel' >Gaat wel<\/option><option value='Slecht' >Slecht<\/option><option value='Zeer slecht' >Zeer slecht<\/option><\/select><\/div><\/div><fieldset id=\"field_1_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Welke klachten heeft u?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_13'><div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Gaatjes'  id='choice_1_13_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Gaatjes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Pijn aan kiezen\/tanden'  id='choice_1_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>Pijn aan kiezen\/tanden<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Rottende kiezen\/tanden'  id='choice_1_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Rottende kiezen\/tanden<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Afgebroken tanden\/kiezen'  id='choice_1_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>Afgebroken tanden\/kiezen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Losgekomen vullingen'  id='choice_1_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_5' id='label_1_13_5' class='gform-field-label gform-field-label--type-inline'>Losgekomen vullingen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Zenuwpijn'  id='choice_1_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_6' id='label_1_13_6' class='gform-field-label gform-field-label--type-inline'>Zenuwpijn<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Nare mondgeur'  id='choice_1_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_7' id='label_1_13_7' class='gform-field-label gform-field-label--type-inline'>Nare mondgeur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Ontstekingen'  id='choice_1_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_8' id='label_1_13_8' class='gform-field-label gform-field-label--type-inline'>Ontstekingen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.9' type='checkbox'  value='Tandvleesproblemen'  id='choice_1_13_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_9' id='label_1_13_9' class='gform-field-label gform-field-label--type-inline'>Tandvleesproblemen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.11' type='checkbox'  value='Tandplak\/Tandsteen'  id='choice_1_13_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_11' id='label_1_13_11' class='gform-field-label gform-field-label--type-inline'>Tandplak\/Tandsteen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.12' type='checkbox'  value='Losse kiezen\/tanden'  id='choice_1_13_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_12' id='label_1_13_12' class='gform-field-label gform-field-label--type-inline'>Losse kiezen\/tanden<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_13_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.13' type='checkbox'  value='Zwarte kiezen\/tanden'  id='choice_1_13_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_13_13' id='label_1_13_13' class='gform-field-label gform-field-label--type-inline'>Zwarte kiezen\/tanden<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_14\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Vertel wat er mis is met uw tanden of kiezen en welke problemen u ervaart:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_1_14' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Hoelang heeft u deze klachten?<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Hoe is erg is de pijn op een schaal van 1 tot 10?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_16' id='input_1_16' type='number' step='any' min='1' max='10' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_1_16\" \/><div class='gfield_description instruction ' id='gfield_instruction_1_16'>Voer een nummer in van <strong>1<\/strong> tot <strong>10<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_1_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Heeft u een kunstgebit?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_17'>\n\t\t\t<div class='gchoice gchoice_1_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Ja'  id='choice_1_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_0' id='label_1_17_0' class='gform-field-label gform-field-label--type-inline'>Ja<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Nee'  id='choice_1_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_1' id='label_1_17_1' class='gform-field-label gform-field-label--type-inline'>Nee<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Gedeeltelijk'  id='choice_1_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_17_2' id='label_1_17_2' class='gform-field-label gform-field-label--type-inline'>Gedeeltelijk<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Wanneer bent u voor het laatst bij een tandarts geweest?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_20'>\n\t\t\t<div class='gchoice gchoice_1_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Minder dan 6 maanden geleden'  id='choice_1_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_0' id='label_1_20_0' class='gform-field-label gform-field-label--type-inline'>Minder dan 6 maanden geleden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='6 maanden tot 1 jaar geleden'  id='choice_1_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>6 maanden tot 1 jaar geleden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='1 jaar tot 2 jaar geleden'  id='choice_1_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>1 jaar tot 2 jaar geleden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Tussen de 2 en 3 jaar geleden'  id='choice_1_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3' class='gform-field-label gform-field-label--type-inline'>Tussen de 2 en 3 jaar geleden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Langer dan 3 jaar geleden'  id='choice_1_20_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_4' id='label_1_20_4' class='gform-field-label gform-field-label--type-inline'>Langer dan 3 jaar geleden<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_20_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Nog nooit'  id='choice_1_20_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_20_5' id='label_1_20_5' class='gform-field-label gform-field-label--type-inline'>Nog nooit<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Bij welke tandartspraktijk staat u ingeschreven?<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>Welke medicijnen gebruikt u? (voor verdovingen e.d.)<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_1_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>Geef een korte en duidelijke schets van uw persoonlijke situatie?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_1_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Welke situatie is het meeste op u van toepassing?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_1_22' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Ik heb betaald werk of een eigen bedrijf' >Ik heb betaald werk of een eigen bedrijf<\/option><option value='Ik heb een WW-uitkering of bijstandsuitkering' >Ik heb een WW-uitkering of bijstandsuitkering<\/option><option value='Ik ben werkloos\/werkzoekende' >Ik ben werkloos\/werkzoekende<\/option><option value='Ik ben gepensioneerd of met vervroegd pensioen' >Ik ben gepensioneerd of met vervroegd pensioen<\/option><option value='Ik ben arbeidsongeschikt (WAO, WAZ, WIA, Wajong)' >Ik ben arbeidsongeschikt (WAO, WAZ, WIA, Wajong)<\/option><option value='Ik ben scholier of studerende' >Ik ben scholier of studerende<\/option><option value='Ik ben huisman\/huisvrouw' >Ik ben huisman\/huisvrouw<\/option><option value='Ik ben dakloos' >Ik ben dakloos<\/option><\/select><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>Welke zorgverzekering heeft u op dit moment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_1_23' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Alleen een basisverzekering' >Alleen een basisverzekering<\/option><option value='Een basisverzekering + aanvullende verzekering' >Een basisverzekering + aanvullende verzekering<\/option><option value='Een basisverzekering + tandartsverzekering' >Een basisverzekering + tandartsverzekering<\/option><option value='Een basisverzekering + aanvullende verzekering + tandartsverzekering' >Een basisverzekering + aanvullende verzekering + tandartsverzekering<\/option><option value='Een gemeentelijke zorgpolis' >Een gemeentelijke zorgpolis<\/option><option value='Geen zorgverzekering' >Geen zorgverzekering<\/option><\/select><\/div><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Geef aan wat op u van toepassing is:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_24'><div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Ik heb schulden'  id='choice_1_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>Ik heb schulden<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Ik heb schulden bij de zorgverzekeraar'  id='choice_1_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_2' id='label_1_24_2' class='gform-field-label gform-field-label--type-inline'>Ik heb schulden bij de zorgverzekeraar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Ik sta onder bewindvoering'  id='choice_1_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_3' id='label_1_24_3' class='gform-field-label gform-field-label--type-inline'>Ik sta onder bewindvoering<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.4' type='checkbox'  value='Ik ben gedupeerde van de toeslagenaffaire'  id='choice_1_24_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_4' id='label_1_24_4' class='gform-field-label gform-field-label--type-inline'>Ik ben gedupeerde van de toeslagenaffaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.5' type='checkbox'  value='Ik heb thuiswonende kinderen'  id='choice_1_24_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_5' id='label_1_24_5' class='gform-field-label gform-field-label--type-inline'>Ik heb thuiswonende kinderen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_24_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.6' type='checkbox'  value='Ik woon samen met mijn partner'  id='choice_1_24_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_24_6' id='label_1_24_6' class='gform-field-label gform-field-label--type-inline'>Ik woon samen met mijn partner<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ik ga akkoord met het privacystatement en geef toestemming tot het verwerken van mijn gegevens<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Vereist)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_25'><div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='Ja akkoord'  id='choice_1_25_1'   aria-describedby=\"gfield_description_1_25\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>Ja akkoord<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_25'>Dit formulier is naar waarheid en in samenspraak met de client en evt. partner ingevuld. Client heeft expliciet toestemming gegeven voor het verstrekken van zijn\/haar persoonsgegevens aan Stichting ANDERS Amstelland, SUN Amstelveen en het behandeld tandartsteam. De client en evt partner verlenen toestemming voor het verwerken van de ingevoerde gegevens. De client en evt partner kan ten alle tijden aanvragen om de gegevens te laten verwijderen in de systemen van de organisaties.<\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Versturen'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='{&quot;inputPrimaryColor&quot;:&quot;#cf2e2e&quot;,&quot;buttonPrimaryBackgroundColor&quot;:&quot;#cf2e2e&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='CkjXfFIUV9ZkWSzWkYVnk2S2457kwD6W65XWW6Ggj1kNRF8v1pmGtXhwi\/017vJ\/qpwRqN2vHp+4Zwq45LetQXzbUEv4Pm3Sj0yLzceULrES+lo=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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Meld je aan middels het aanmeldformulier hier links op de pagina. <\/p>\n\n\n\n<p>We nemen telefonisch contact met je op om je aanmelding door te nemen. Als je aanmelding voldoet aan de criteria gaan we kijken wat we voor je kunnen betekenen.<\/p>\n<\/div>\n<\/div>\n\n\n\n<p><\/p>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center has-text-color\" style=\"color:#cb063e\">Samenwerking<\/h2>\n\n\n\n<p class=\"has-text-align-center\">Deze organisaties leveren een bijdrage om het werk van de Sociale Tandarts in Amstelveen mogelijk te maken.<\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-28f84493 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:25%\">\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/stichtinganders.nl\/amstelland\/\" target=\"_blank\" rel=\" noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"394\" src=\"http:\/\/socialetandarts.nl\/amstelveen\/wp-content\/uploads\/sites\/4\/2026\/02\/Logo-Stichting-ANDERS-regio-Amstelland-1024x394.png\" 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href=\"https:\/\/sunamstelveen.nl\/\" target=\"_blank\" rel=\" noreferrer noopener\"><img loading=\"lazy\" decoding=\"async\" width=\"2418\" height=\"1400\" src=\"http:\/\/socialetandarts.nl\/amstelveen\/wp-content\/uploads\/sites\/4\/2026\/02\/logo_sunamstelveen_color.png\" alt=\"\" class=\"wp-image-40\" srcset=\"https:\/\/socialetandarts.nl\/amstelveen\/wp-content\/uploads\/sites\/4\/2026\/02\/logo_sunamstelveen_color.png 2418w, https:\/\/socialetandarts.nl\/amstelveen\/wp-content\/uploads\/sites\/4\/2026\/02\/logo_sunamstelveen_color-300x174.png 300w, https:\/\/socialetandarts.nl\/amstelveen\/wp-content\/uploads\/sites\/4\/2026\/02\/logo_sunamstelveen_color-1024x593.png 1024w, https:\/\/socialetandarts.nl\/amstelveen\/wp-content\/uploads\/sites\/4\/2026\/02\/logo_sunamstelveen_color-768x445.png 768w, https:\/\/socialetandarts.nl\/amstelveen\/wp-content\/uploads\/sites\/4\/2026\/02\/logo_sunamstelveen_color-1536x889.png 1536w, 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Meld je aan middels het aanmeldformulier hier links op de pagina. We nemen telefonisch contact met je op om je aanmelding door te nemen. 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