{"id":12508,"date":"2023-08-02T10:11:55","date_gmt":"2023-08-02T08:11:55","guid":{"rendered":"https:\/\/poliklinika.vaslekar.sk\/registration-form\/"},"modified":"2024-07-15T10:25:34","modified_gmt":"2024-07-15T08:25:34","slug":"registration-form","status":"publish","type":"page","link":"https:\/\/poliklinika.vaslekar.sk\/en\/registration-form\/","title":{"rendered":"Registration Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"12508\" class=\"elementor elementor-12508 elementor-3128\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-71722bc e-flex e-con-boxed e-con e-parent\" data-id=\"71722bc\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-73658f2 elementor-widget elementor-widget-template\" data-id=\"73658f2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"template.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-template\">\n\t\t\t\t\t<div data-elementor-type=\"container\" data-elementor-id=\"12813\" class=\"elementor elementor-12813 elementor-3131 elementor-3131\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0a65e27 e-flex e-con-boxed e-con e-parent\" data-id=\"0a65e27\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-a3b9e5e e-flex e-con-boxed e-con e-parent\" data-id=\"a3b9e5e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-af0f697 elementor-widget elementor-widget-html\" data-id=\"af0f697\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>var inputData = {\n\t\tfirstName: \"\",\n\t\temail: \"\",\n\t\tbirthDate: \"\",\n\t\taddress: \"\",\n\t\tzip: \"\",\n\t\tlastName: \"\",\n\t\tbirthNumber: \"\",\n\t\tcity: \"\",\n\t\tphone: \"\",\n\t};\n\n\tvar currentStep = 1;\n\t\n\t\n\n\t\/\/ Function to update the global object\n\tfunction handleInputChange(event) {\n\t\tinputData[event.target.name] = event.target.value;\n\t\tconst isValid = Object.keys(inputData).filter((key) => {\n\t\t\treturn inputData[key] === \"\";\n\t\t});\n\t\tif (isValid.length === 0) {\n\t\t\tdocument.querySelector(\"button.button-next\").disabled = false;\n\t\t} else {\n\t\t\tdocument.querySelector(\"button.button-next\").disabled = true;\n\t\t}\n\t}\n\t\n\tfunction setCurrentStep(step){\n\t    document.querySelectorAll(`.step`).forEach((element) => {\n            element.classList.remove(\"step-active\");\n        });\n        document.querySelector(`.step.step-${step}`).classList.add(\"step-active\");\n        currentStep = step;\n        window.scrollTo({top: 0, behavior: \"smooth\"});\n\t}\n\t\n\t\n\tfunction handleNextStep(e){\n\t   e.preventDefault();\n\t   Object.keys(inputData).forEach((key) => {\n\t\t\tdocument.querySelector(`.value.${key}`).innerHTML = inputData[key]\n\t   });\n\t   currentStep = 2;\n\t   setCurrentStep(2);\n\t   \n\t}\n\t\n\tfunction handleSubmit(e){\n        \/\/<---- EDIT THIS SECTION ---->document.querySelector(\"button.button-pay\").disabled = true;\n        \n        document.querySelector(\"button.button-pay\").innerText = \"Pros\u00edm po\u010dkajte ...\"\n\n        \n        console.log(\"Submit\")\n    }\n\t\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7fb934a elementor-widget elementor-widget-html\" data-id=\"7fb934a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style>.step {\n        max-height: 80px;\n        transition: max-height 0.5s ease-out;\n        overflow: hidden;\n    }\n    \n   .step.step-active {\n        max-height: 1000px;\n        transition: max-height 0.5s ease-in;\n    }\n\n    .step-active .button-prev, .step-active .completed-icon {\n        max-height:0px;\n        width:0px !important;\n        overflow: hidden;\n        transition: all 0.2s;\n        transition-delay: 0.5s;\n    }\n    \n    .step:not(.step-active) .button-prev, .step:not(.step-active) .completed-icon {\n            max-height:30px;\n            overflow: hidden;\n            transition: all 0.2s;\n            width:fit-content;\n    }\n    \n     .step:not(.step-active) .e-con-inner{\n         gap: 0px;\n     }\n     \n     .step.step-active .heading-wrap .e-con-inner{\n         gap: 0px;\n     }\n     \n    .step:not(.step-active) .heading{\n        height: fit-content;\n    }\n    \n    .step:not(.step-active):not(.step-1) .heading h2.elementor-heading-title{\n        color: #ACAAAF;\n    }\n    \n    .step:not(.step-active) .content {\n        transition: opacity 0.3s;\n        transition-delay: 0.3s;\n        opacity: 0;\n    }\n    \n    .step.step-active .content {\n        opacity: 1;\n        transition: opacity 0.3s;\n    }\n    \n    \n    .step:not(.step-active) .heading .number {\n        max-height: 0px;\n        overflow: hidden;\n        transition: all 0.1s;\n    }\n    \n    .step:not(.step-active) .heading {\n        gap: 0px;\n        transition: all 0.1s;\n    }\n    \n    .step.step-active .heading .number {\n        max-height: 100px;\n        transition: all 0.5s;\n    }\n    \n    .step.step-active .heading {\n        gap: 8px;\n        transition: all 0.5s;\n    }\n    \n    .step:not(.step-active) .heading .subtext {\n        display: none;\n    }\n    \n    \n    \/*Button*\/\n    \n    form button.button-primary {\n\t\tpadding: 14px 24px;\n\t\twidth: fit-content;\n\t\tfont-size: 16px;\n\t\tfont-weight: 700;\n\t\tborder: none;\n\t\tline-height: 20px;\n\t\ttransition: all 0.3s;\n\t}\n\t\n\tbutton.button-primary:disabled {\n\t\tcolor: #979799;\n\t\tbackground-color: #e3e3e4;\n\t}\n\n\tbutton.button-primary {\n\t\tcolor: white;\n\t\tbackground-color: #3a4ddb;\n\t}\n\t\n    button.button-primary:not(:disabled):hover {\n        background-color: #000B62;\n        color: white;\n    }\n    \n    button.button-primary:not(:disabled):focus {\n        background-color: #000B62;\n        \n        outline: none;\n    }\n    \n    @media screen and (max-width:767px){\n        .step-2 {\n            max-height: 60px;\n            \n        }\n        \n        button.button-primary {\n            width: 100% !important;\n        }\n    }\n    \n    \n    \n    \n<\/style>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a58d381 e-flex e-con-boxed e-con e-parent\" data-id=\"a58d381\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-adc8895 e-con-full secondary-navigation e-flex e-con e-parent\" data-id=\"adc8895\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-8d00090 e-flex e-con-boxed e-con e-parent\" data-id=\"8d00090\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-1ac1fc7 e-con-full lekarne e-flex e-con e-parent\" data-id=\"1ac1fc7\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1321f70 elementor-widget elementor-widget-heading\" data-id=\"1321f70\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Order form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-61e336d elementor-widget elementor-widget-heading\" data-id=\"61e336d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\"><span>Annual membership<\/span><\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-33fac68 e-con-full e-flex e-con e-parent\" data-id=\"33fac68\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-625ad26 elementor-align-right button-back elementor-hidden-tablet elementor-hidden-mobile elementor-widget elementor-widget-button\" data-id=\"625ad26\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Back to<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-f8ce172 e-flex e-con-boxed e-con e-parent\" data-id=\"f8ce172\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-4317ba9 e-flex e-con-boxed e-con e-parent\" data-id=\"4317ba9\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-147fa3c e-flex e-con-boxed e-con e-parent\" data-id=\"147fa3c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-348024c step step-1 step-active e-flex e-con-boxed e-con e-parent\" data-id=\"348024c\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-2d67d01 e-con-full heading e-flex e-con e-parent\" data-id=\"2d67d01\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-209f1a7 number elementor-widget elementor-widget-heading\" data-id=\"209f1a7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\">1 <span>\/ 4<\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-22f6280 e-flex e-con-boxed e-con e-parent\" data-id=\"22f6280\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-6cdfc7b heading-wrap e-con-full e-flex e-con e-parent\" data-id=\"6cdfc7b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-efeca86 completed-icon elementor-widget-mobile__width-auto elementor-view-default elementor-widget elementor-widget-icon\" data-id=\"efeca86\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<div class=\"elementor-icon\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"28\" height=\"28\" viewBox=\"0 0 28 28\" fill=\"none\"><rect width=\"28\" height=\"28\" rx=\"14\" fill=\"url(#paint0_radial_3509_40382)\"><\/rect><path d=\"M11.5962 16.9063L8.46869 13.7788L7.40369 14.8363L11.5962 19.0288L20.5962 10.0288L19.5387 8.97125L11.5962 16.9063Z\" fill=\"white\"><\/path><defs><radialGradient id=\"paint0_radial_3509_40382\" cx=\"0\" cy=\"0\" r=\"1\" gradientUnits=\"userSpaceOnUse\" gradientTransform=\"translate(14 35.3727) rotate(-90) scale(35.5833 35.2391)\"><stop offset=\"0.203249\" stop-color=\"#41DEB9\"><\/stop><stop offset=\"1\" stop-color=\"#394CDA\"><\/stop><\/radialGradient><\/defs><\/svg>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cd4c2d8 elementor-widget-mobile__width-initial elementor-widget elementor-widget-heading\" data-id=\"cd4c2d8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Basic personal data<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-314a896 elementor-widget elementor-widget-html\" data-id=\"314a896\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<button class=\"button-prev\" onclick=\"setCurrentStep(1)\">Edit by<\/button>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-292dcd8 e-con-full content e-flex e-con e-parent\" data-id=\"292dcd8\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-b91ccab e-con-full slide-wraper e-flex e-con e-parent\" data-id=\"b91ccab\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-11b3030 e-con-full e-flex e-con e-parent\" data-id=\"11b3030\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6135939 elementor-widget elementor-widget-html\" data-id=\"6135939\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<form onsubmit=\"handleNextStep(event)\">\n\t<div class=\"wrap\">\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-wrap\">\n\t\t\t\t<input type=\"text\" name=\"firstName\" oninput=\"handleInputChange(event)\" id=\"firstName\" placeholder=\"Name *\">\n\t\t\t\t<input type=\"text\" name=\"lastName\" oninput=\"handleInputChange(event)\" id=\"lastName\" placeholder=\"Surname *\">\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-wrap\">\n\t\t\t\t<input type=\"email\" name=\"email\" oninput=\"handleInputChange(event)\" id=\"email\" placeholder=\"Email *\">\n\t\t\t\t<input type=\"tel\" name=\"phone\" oninput=\"handleInputChange(event)\" id=\"phone\" placeholder=\"Telephone *\">\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-wrap\">\n\t\t\t\t<input type=\"text\" name=\"birthDate\" oninput=\"handleInputChange(event)\" id=\"birthDate\" placeholder=\"Date of birth *\">\n\t\t\t\t<input type=\"text\" name=\"birthNumber\" oninput=\"handleInputChange(event)\" id=\"birthNumber\" placeholder=\"Birth number *\">\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-wrap\">\n\t\t\t\t<input type=\"text\" name=\"address\" oninput=\"handleInputChange(event)\" id=\"address\" placeholder=\"Address *\">\n\t\t\t\t<input type=\"text\" name=\"city\" oninput=\"handleInputChange(event)\" id=\"city\" placeholder=\"City *\">\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-wrap\">\n\t\t\t\t<input type=\"text\" name=\"zip\" oninput=\"handleInputChange(event)\" id=\"zip\" placeholder=\"POSTCODE *\">\n\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"row\">\n\t\t\t<div class=\"col-wrap\">\n\t\t\t\t<button disabled type=\"submit\" class=\"button-primary button-next\">\n  Continue\n\t\t\t\t<\/button>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/form>\n\n\n<style>\n\tform {\n\t\tdisplay: flex;\n\t\tgap: 24px;\n\t\tmax-width: 800px;\n\t\tfont-family: \"Red Hat Display\";\n\t}\n\t\n\tform .wrap {\n\t    display: flex;\n\t    flex-direction: column;\n\t    gap: 24px;\n\t    width: 100%\n\t}\n\n\tform .col-wrap {\n\t\tdisplay: grid;\n\t\tgrid-template-columns: 1fr 1fr;\n\t\tgap: 24px;\n\t}\n\n\tform .row input {\n\t\tborder-radius: 100px 100px 100px 100px;\n\t\tfont-weight: 400;\n\t\tcolor: #000b62;\n\t\tborder: 1px solid #c9c4cf;\n\t\tpadding: 12px 20px;\n\t}\n\n\tform .row input:hover {\n\t\tborder-color: #000b62;\n\t}\n\n\tform input:focus {\n\t\toutline-color: #3a4ddb;\n\t}\n\t\n\t@media screen and (max-width:767px){\n\t    form .col-wrap {\n    \t\tgrid-template-columns: 1fr;\n    \t\tgap: 16px;\n    \t}\n\t}\n<\/style>\n\n\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-6261b47 step step-2 e-flex e-con-boxed e-con e-parent\" data-id=\"6261b47\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-844635e e-con-full heading e-flex e-con e-parent\" data-id=\"844635e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-542e4d6 number elementor-widget elementor-widget-heading\" data-id=\"542e4d6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\">2 <span>\/ 4<\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e697e46 elementor-widget elementor-widget-heading\" data-id=\"e697e46\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Control of personal data<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fde5016 subtext elementor-widget elementor-widget-heading\" data-id=\"fde5016\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Please check the accuracy of the information below.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d66cdcc e-con-full e-flex e-con e-parent\" data-id=\"d66cdcc\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-3651980 e-con-full slide-wraper e-flex e-con e-parent\" data-id=\"3651980\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-d73c266 e-con-full content e-flex e-con e-parent\" data-id=\"d73c266\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f3efe30 elementor-widget elementor-widget-html\" data-id=\"f3efe30\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<form class=\"check-fields\" onsubmit=\"handleSubmit(event)\">\n\t<div class=\"wrap\">\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">Name and surname<\/div>\n\t\t\t<div>\n\t\t\t    <span class=\"firstName value\"><\/span> \n\t\t\t    <span class=\"lastName value\"><\/span>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">E-mail<\/div>\n\t\t\t<div class=\"email value\"><\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">Phone number<\/div>\n\t\t\t<div class=\"phone value\">Phone more<\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">Date of birth<\/div>\n\t\t\t<div class=\"birthDate value\"><\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">Birth number<\/div>\n\t\t\t<div class=\"birthNumber value\"><\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">Address<\/div>\n\t\t\t<div class=\"address value\"><\/div>\n\t\t<\/div>\n\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">City<\/div>\n\t\t\t<div class=\"city value\"><\/div>\n\t\t<\/div>\n\t\t<div class=\"row\">\n\t\t\t<div class=\"label\">POSTCODE<\/div>\n\t\t\t<div class=\"zip value\"><\/div>\n\t\t<\/div>\n\t\t<div class=\"accept\">\n\t\t    <div class=\"field\">\n\t\t        <input type=\"checkbox\" id=\"accept1\" name=\"accept1\" required=\"\">\n\t\t        <label for=\"accept1\">I have familiarised myself with the rules of <a href=\"#\">Lorme ipsum<\/a><\/label>\n\t\t    <\/div>\n\t\t    \n\t\t    <div class=\"field\">\n\t\t        <input type=\"checkbox\" id=\"accept2\" name=\"accept1\" required=\"\">\n\t\t        <label for=\"accept2\">I consent to the processing of my <a href=\"#\">personal data. <\/a><\/label>\n\t\t    <\/div>\n\t\t    \n\t\t    <button type=\"submit\" class=\"button-primary button-pay\">Go to payment<\/button>\n\t\t<\/div>\n\t<\/div>\n<\/form>\n\n<style>\n    .check-fields {\n        font-family: \"Red Hat Display\";\n        max-width: 700px\n    }\n\t.check-fields .row {\n\t\twidth: 100%;\n\t\tdisplay: grid;\n\t\tgrid-template-columns: 1fr 1fr;\n\t\tfont-size: 16px;\n\t\tcolor: #000B62;\n\t}\n\t\n\t.check-fields .wrap {\n\t    display: flex;\n\t    gap: 16px;\n\t    flex-direction: column;\n\t}\n\t\n\t.check-fields .value{\n\t    font-weight: 400;\n\t}\n\t\n\t.check-fields .label{\n\t    font-weight: 500;\n\t}\n\t\n\t.value.phone, .value.email, .value.birthDate, .value.birthNumber{\n\t    font-weight: 700;\n\t}\n\t\n\t.button-pay{\n\t    margin-top: 32px;\n\t    margin-bottom: 24px;\n\t}\n\t\n\t\n\t\/*Checkboxes*\/\n\t.accept {\n\t    display: flex;\n\t    flex-direction: column;\n\t    gap: 16px;\n\t    margin-top: 32px;\n\t}\n\t\n\t\n\t.accept a{\n\t    transition: all 0.2s;\n\t    font-weight: 700;\n\t    color: #000B62;\n\t    text-decoration: underline;\n\t}\n\t\n\t.accept a:hover{\n\t    color: #3A4DDB;\n\t}\n\t\n\t.accept .field{\n\t    display: flex;\n\t    gap: 16px;\n\t    align-items: middle;\n\t}\n\t\n\t.accept .field input{\n\t    -webkit-appearance: none;\n\t}\n\t\n\t.accept .field input::before{\n\t    content: \"\";\n\t    height: 18px;\n\t    width: 18px;\n\t    border: 2px solid #3A4DDB;\n\t    border-radius: 2px;\n\t     display: flex;\n\t     justify-content: baseline;\n\t}\n\t\n\t.accept .field input:checked::before{\n\t    background: url('data:image\/png;base64,iVBORw0KGgoAAAANSUhEUgAAAA8AAAALCAYAAACgR9dcAAAACXBIWXMAAAsTAAALEwEAmpwYAAAAAXNSR0IArs4c6QAAAARnQU1BAACxjwv8YQUAAABhSURBVHgBpZDBDcAgDAPpBh2hI3T\/DyN0BLpBR3CN8AMkQAlEskDAHYEjOAvAxSEyb\/BUBpmEUmkZVAcbICfnzDK9UQsfc7tAHYjabASmN6rtpxbA8zkdgQ0cCOxgR2ACfzET8i9qyuheAAAAAElFTkSuQmCC') center;\n\t    background-repeat: no-repeat;\n\t    background-size: 13px;\n\t    font-size: 10px;\n\t    background-color: #3A4DDB;\n\t    color: white;\n\t    \n\t}\n\t\n\t@media screen and (max-width:767px){\n\t    .check-fields .row {\n\t        grid-template-columns: 1fr;\n\t        gap: 4px;\n\t    }\n\t    .check-fields .accept label{\n\t        line-height: 1.2em;\n\t    }\n\t    .button-pay {\n\t        margin-bottom: 0px;\n\t    }\n\t}\n\t\n\t\n\t\n<\/style>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":12,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-12508","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/poliklinika.vaslekar.sk\/en\/wp-json\/wp\/v2\/pages\/12508","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/poliklinika.vaslekar.sk\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/poliklinika.vaslekar.sk\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/poliklinika.vaslekar.sk\/en\/wp-json\/wp\/v2\/users\/12"}],"replies":[{"embeddable":true,"href":"https:\/\/poliklinika.vaslekar.sk\/en\/wp-json\/wp\/v2\/comments?post=12508"}],"version-history":[{"count":0,"href":"https:\/\/poliklinika.vaslekar.sk\/en\/wp-json\/wp\/v2\/pages\/12508\/revisions"}],"wp:attachment":[{"href":"https:\/\/poliklinika.vaslekar.sk\/en\/wp-json\/wp\/v2\/media?parent=12508"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}