{"id":5175,"date":"2024-11-15T15:41:15","date_gmt":"2024-11-15T15:41:15","guid":{"rendered":"https:\/\/lassustandartsen.nl\/lelystad\/complaints-form\/"},"modified":"2024-11-15T15:42:24","modified_gmt":"2024-11-15T15:42:24","slug":"complaints-form","status":"publish","type":"page","link":"https:\/\/lassustandartsen.nl\/lelystad\/en\/complaints-form\/","title":{"rendered":"Complaints Form"},"content":{"rendered":"<!-- HTML Forms v1.6.4 - https:\/\/wordpress.org\/plugins\/html-forms\/ -->\n<form method=\"post\"  class=\"hf-form hf-form-4610 \" data-id=\"4610\" data-title=\"Complaints form\" data-slug=\"complaints-form\" data-message-success=\"Thank you! We will be in touch soon.\" data-message-invalid-email=\"Sorry, that email address looks invalid.\" data-message-required-field-missing=\"Please fill in the required fields.\" data-message-error=\"Oops. An error occurred.\" data-message-recaptcha-failed=\"reCAPTCHA verification failed. Please try again.\" data-message-recaptcha-low-score=\"Your submission appears to be spam. Please try again.\" data-message-file-too-large=\"Uploaded file is too large.\" data-message-file-upload-error=\"An upload error occurred. Please try again later.\" data-message-submission-limit-reached=\"The submission limit for this form has been reached.\" data-message-require-user-logged-in=\"You must be logged in before you can use this form.\"><input type=\"hidden\" name=\"_hf_form_id\" value=\"4610\" \/><div style=\"display: none;\"><input type=\"text\" name=\"_hf_h4610\" value=\"\" \/><\/div><div class=\"hf-fields-wrap\"><div class=\"grid lg:grid-cols-2 gap-[30px] referral-form\">\r\n\r\n\t<div>\r\n\t\t<label for=\"first-name\" class=\"block mb-2\">First name*<\/label>\r\n\t\t<input type=\"text\" name=\"first-name\" id=\"first-name\" placeholder=\"First name\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"last-name\" class=\"block mb-2\">Surname*<\/label>\r\n\t\t<input type=\"text\" name=\"last-name\" id=\"last-name\" placeholder=\"Surname\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div>\r\n\t\t<label for=\"birth-date\" class=\"block mb-2\">Birth date*<\/label>\r\n\t\t<input type=\"date\" name=\"birth-date\" id=\"birth-date\" placeholder=\"Voer je geboorte datum in\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"typeof\" class=\"block mb-2\">What is the nature of your complaint?*<\/label>\r\n\t\t<select name=\"typeof\" id=\"typeof\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t\t\t<option value=\"\">Select<\/option>\t\r\n\t\t\t<option value=\"Dental\">Dental<\/option>\r\n\t\t\t<option value=\"Administrative\">Administrative<\/option>\r\n\t\t\t<option value=\"Provision of information\">Provision of information<\/option>\r\n          \t<option value=\"Treatment\">Treatment<\/option>\r\n\t\t<\/select>\r\n\t<\/div>\r\n\r\n\t<div>\r\n\t\t<label for=\"phone\" class=\"block mb-2\">Phone number*<\/label>\r\n\t\t<input type=\"tel\" name=\"phone\" id=\"phone\" placeholder=\"Phone number\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"email\" class=\"block mb-2\">Email address*<\/label>\r\n\t\t<input type=\"email\" name=\"email\" id=\"email\" placeholder=\"Email address\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2\">\r\n\t\t<label for=\"timetoreach\" class=\"block mb-2\">When is the right time to reach up to you?*<\/label>\r\n\t\t<input type=\"text\" name=\"timetoreach\" id=\"timetoreach\" required=\"true\" placeholder=\"\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2\">\r\n\t\t<label for=\"whathappened\" class=\"block mb-2\">What happened?* <\/label>\r\n\t\t<textarea name=\"whathappened\" id=\"whathappened\" required=\"true\" placeholder=\"\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\"><\/textarea>\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2\">\r\n\t\t<label for=\"why\" class=\"block mb-2\"> How come you are dissatisfied?* <\/label>\r\n\t\t<textarea name=\"why\" id=\"why\" required=\"true\" placeholder=\"\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\"><\/textarea>\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2\">\r\n\t\t<label for=\"sppken\" class=\"block mb-2\"> Have you spoken about this with someone from Lassus Tandartsen? 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