{"id":95,"date":"2019-03-11T19:16:40","date_gmt":"2019-03-11T15:16:40","guid":{"rendered":"http:\/\/modernhospital.az\/newsite\/?page_id=95"},"modified":"2019-05-08T13:35:03","modified_gmt":"2019-05-08T09:35:03","slug":"memnuniyyet-anketi","status":"publish","type":"page","link":"https:\/\/modernhospital.az\/newsite\/e-xidmetler\/memnuniyyet-anketi\/","title":{"rendered":"M\u0259mnuniyy\u0259t anketi"},"content":{"rendered":"<p>[vc_row][vc_column][vc_column_text]<\/p>\n<div class=\"caldera-grid\" id=\"caldera_form_1\" data-cf-ver=\"1.9.3\" data-cf-form-id=\"CF5cd2875938ffa\"><div id=\"caldera_notices_1\" data-spinner=\"https:\/\/modernhospital.az\/newsite\/wp-admin\/images\/spinner.gif\"><\/div><form data-instance=\"1\" class=\"CF5cd2875938ffa caldera_forms_form cfajax-trigger\" method=\"POST\" enctype=\"multipart\/form-data\" id=\"CF5cd2875938ffa_1\" data-form-id=\"CF5cd2875938ffa\" aria-label=\"M\u0259mnuniyy\u0259t anketi\" data-target=\"#caldera_notices_1\" data-template=\"#cfajax_CF5cd2875938ffa-tmpl\" data-cfajax=\"CF5cd2875938ffa\" data-load-element=\"_parent\" data-load-class=\"cf_processing\" data-post-disable=\"0\" data-action=\"cf_process_ajax_submit\" data-request=\"https:\/\/modernhospital.az\/newsite\/cf-api\/CF5cd2875938ffa\" data-hiderows=\"true\">\r\n<input type=\"hidden\" id=\"_cf_verify_CF5cd2875938ffa\" name=\"_cf_verify\" value=\"58286c1362\"  data-nonce-time=\"1779782290\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/newsite\/wp-json\/wp\/v2\/pages\/95\" \/><div id=\"cf2-CF5cd2875938ffa_1\"><\/div><input type=\"hidden\" name=\"_cf_frm_id\" value=\"CF5cd2875938ffa\">\r\n<input type=\"hidden\" name=\"_cf_frm_ct\" value=\"1\">\r\n<input type=\"hidden\" name=\"cfajax\" value=\"CF5cd2875938ffa\">\r\n<input type=\"hidden\" name=\"_cf_cr_pst\" value=\"95\">\r\n<div class=\"hide\" style=\"display:none; overflow:hidden;height:0;width:0;\">\r\n<label>Phone<\/label><input type=\"text\" name=\"phone\" value=\"\" autocomplete=\"off\">\r\n<\/div><div id=\"CF5cd2875938ffa_1-row-1\"  class=\"row  first_row\"><div  class=\"col-sm-12  single\"><div class=\"\"><div style=\"width: 100%; height: 20px;\"><\/div>\n<h3 style=\"color: #e4032c;\">\u015e\u0259xsi m\u0259lumatlar<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-2\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_9229251\" class=\"form-group\" id=\"fld_9229251_1-wrap\">\r\n\t<label id=\"fld_9229251Label\" for=\"fld_9229251_1\" class=\"control-label\">Ad\u0131n\u0131z, Soyad\u0131n\u0131z <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"Ad\u0131n\u0131z, Soyad\u0131n\u0131z\"  required type=\"text\" data-field=\"fld_9229251\" class=\" form-control\" id=\"fld_9229251_1\" name=\"fld_9229251\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9229251Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_17370\" class=\"form-group\" id=\"fld_17370_1-wrap\">\r\n<label id=\"fld_17370Label\" for=\"fld_17370_1\" class=\"control-label\">Anketi dolduran \u015f\u0259xs <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Pasient\" for=\"fld_17370_1_opt302917\"><input type=\"radio\" id=\"fld_17370_1_opt302917\" data-field=\"fld_17370\" class=\"fld_17370_1 option-required\" name=\"fld_17370\" value=\"Pasient\"   required=\"required\" data-radio-field=\"fld_17370_1\" data-type=\"radio\" data-calc-value=\"Pasient\" \/>\n\t\t\tPasient\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Pasientin yax\u0131n\u0131\" for=\"fld_17370_1_opt1544251\"><input type=\"radio\" id=\"fld_17370_1_opt1544251\" data-field=\"fld_17370\" class=\"fld_17370_1 option-required\" name=\"fld_17370\" value=\"Pasientin yax\u0131n\u0131\"   required=\"required\" data-radio-field=\"fld_17370_1\" data-type=\"radio\" data-calc-value=\"Pasientin yax\u0131n\u0131\" \/>\n\t\t\tPasientin yax\u0131n\u0131\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_8514967\" class=\"form-group\" id=\"fld_8514967_1-wrap\">\r\n\t<label id=\"fld_8514967Label\" for=\"fld_8514967_1\" class=\"control-label\">Ya\u015f\u0131n\u0131z <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"number\" data-field=\"fld_8514967\" class=\" form-control\" id=\"fld_8514967_1\" name=\"fld_8514967\" value=\"\" data-type=\"number\" data-parsley-type=\"number\" aria-required=\"true\"   aria-labelledby=\"fld_8514967Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3  last_col\"><div data-field-wrapper=\"fld_4410609\" class=\"form-group\" id=\"fld_4410609_1-wrap\">\r\n<label id=\"fld_4410609Label\" for=\"fld_4410609_1\" class=\"control-label\">\u00d6d\u0259m\u0259 <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Na\u011fd\" for=\"fld_4410609_1_opt950045\"><input type=\"radio\" id=\"fld_4410609_1_opt950045\" data-field=\"fld_4410609\" class=\"fld_4410609_1 option-required\" name=\"fld_4410609\" value=\"Na\u011fd\"   required=\"required\" data-radio-field=\"fld_4410609_1\" data-type=\"radio\" data-calc-value=\"Na\u011fd\" \/>\n\t\t\tNa\u011fd\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"S\u0131\u011fortal\u0131\" for=\"fld_4410609_1_opt1817237\"><input type=\"radio\" id=\"fld_4410609_1_opt1817237\" data-field=\"fld_4410609\" class=\"fld_4410609_1 option-required\" name=\"fld_4410609\" value=\"S\u0131\u011fortal\u0131\"   required=\"required\" data-radio-field=\"fld_4410609_1\" data-type=\"radio\" data-calc-value=\"S\u0131\u011fortal\u0131\" \/>\n\t\t\tS\u0131\u011fortal\u0131\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-3\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_2233638\" class=\"form-group\" id=\"fld_2233638_1-wrap\">\r\n<label id=\"fld_2233638Label\" for=\"fld_2233638_1\" class=\"control-label\">Cinsiniz<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Ki\u015fi\" for=\"fld_2233638_1_opt1111562\"><input type=\"radio\" id=\"fld_2233638_1_opt1111562\" data-field=\"fld_2233638\" class=\"fld_2233638_1\" name=\"fld_2233638\" value=\"Ki\u015fi\"    data-radio-field=\"fld_2233638_1\" data-type=\"radio\" data-calc-value=\"Ki\u015fi\" \/>\n\t\t\tKi\u015fi\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Qad\u0131n\" for=\"fld_2233638_1_opt1543667\"><input type=\"radio\" id=\"fld_2233638_1_opt1543667\" data-field=\"fld_2233638\" class=\"fld_2233638_1\" name=\"fld_2233638\" value=\"Qad\u0131n\"    data-radio-field=\"fld_2233638_1\" data-type=\"radio\" data-calc-value=\"Qad\u0131n\" \/>\n\t\t\tQad\u0131n\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_4811988\" class=\"form-group\" id=\"fld_4811988_1-wrap\">\r\n<label id=\"fld_4811988Label\" for=\"fld_4811988_1\" class=\"control-label\">Ail\u0259 v\u0259ziyy\u0259tiniz<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Evli\" for=\"fld_4811988_1_opt200150\"><input type=\"radio\" id=\"fld_4811988_1_opt200150\" data-field=\"fld_4811988\" class=\"fld_4811988_1\" name=\"fld_4811988\" value=\"Evli\"    data-radio-field=\"fld_4811988_1\" data-type=\"radio\" data-calc-value=\"Evli\" \/>\n\t\t\tEvli\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Subay\" for=\"fld_4811988_1_opt1341619\"><input type=\"radio\" id=\"fld_4811988_1_opt1341619\" data-field=\"fld_4811988\" class=\"fld_4811988_1\" name=\"fld_4811988\" value=\"Subay\"    data-radio-field=\"fld_4811988_1\" data-type=\"radio\" data-calc-value=\"Subay\" \/>\n\t\t\tSubay\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_2930358\" class=\"form-group\" id=\"fld_2930358_1-wrap\">\r\n<label id=\"fld_2930358Label\" for=\"fld_2930358_1\" class=\"control-label\">T\u0259hsiliniz<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"Orta\" for=\"fld_2930358_1_opt123876\"><input type=\"radio\" id=\"fld_2930358_1_opt123876\" data-field=\"fld_2930358\" class=\"fld_2930358_1\" name=\"fld_2930358\" value=\"Orta\"    data-radio-field=\"fld_2930358_1\" data-type=\"radio\" data-calc-value=\"Orta\" \/>\n\t\t\tOrta\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Ali\" for=\"fld_2930358_1_opt1298592\"><input type=\"radio\" id=\"fld_2930358_1_opt1298592\" data-field=\"fld_2930358\" class=\"fld_2930358_1\" name=\"fld_2930358\" value=\"Ali\"    data-radio-field=\"fld_2930358_1\" data-type=\"radio\" data-calc-value=\"Ali\" \/>\n\t\t\tAli\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3  last_col\"><div data-field-wrapper=\"fld_6349640\" class=\"form-group\" id=\"fld_6349640_1-wrap\">\r\n\t<label id=\"fld_6349640Label\" for=\"fld_6349640_1\" class=\"control-label\">Pe\u015f\u0259niz <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"Pe\u015f\u0259niz\"  required type=\"text\" data-field=\"fld_6349640\" class=\" form-control\" id=\"fld_6349640_1\" name=\"fld_6349640\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_6349640Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-4\"  class=\"row \"><div  class=\"col-sm-3  first_col\"><div data-field-wrapper=\"fld_9981974\" class=\"form-group\" id=\"fld_9981974_1-wrap\">\r\n\t<label id=\"fld_9981974Label\" for=\"fld_9981974_1\" class=\"control-label\">\u00dcnvan <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"\u00dcnvan\u0131 qeyd edin\"  required type=\"text\" data-field=\"fld_9981974\" class=\" form-control\" id=\"fld_9981974_1\" name=\"fld_9981974\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_9981974Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_6448462\" class=\"form-group\" id=\"fld_6448462_1-wrap\">\r\n\t<label id=\"fld_6448462Label\" for=\"fld_6448462_1\" class=\"control-label\">Mobil telefon <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '(999)999-9999'\"  required type=\"phone\" data-field=\"fld_6448462\" class=\" form-control\" id=\"fld_6448462_1\" name=\"fld_6448462\" value=\"\" data-type=\"phone\" aria-required=\"true\"   aria-labelledby=\"fld_6448462Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3 \"><div data-field-wrapper=\"fld_4827273\" class=\"form-group\" id=\"fld_4827273_1-wrap\">\r\n\t<label id=\"fld_4827273Label\" for=\"fld_4827273_1\" class=\"control-label\">Ev telefonu<\/label>\r\n\t<div class=\"\">\r\n\t\t<input  data-inputmask=\"'mask': '(999)999-9999'\"   type=\"phone\" data-field=\"fld_4827273\" class=\" form-control\" id=\"fld_4827273_1\" name=\"fld_4827273\" value=\"\" data-type=\"phone\"   aria-labelledby=\"fld_4827273Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-3  last_col\"><div data-field-wrapper=\"fld_4661089\" class=\"form-group\" id=\"fld_4661089_1-wrap\">\r\n\t<label id=\"fld_4661089Label\" for=\"fld_4661089_1\" class=\"control-label\">E-mail <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input   required type=\"email\" data-field=\"fld_4661089\" class=\" form-control\" id=\"fld_4661089_1\" name=\"fld_4661089\" value=\"\" data-type=\"email\" aria-required=\"true\"   aria-labelledby=\"fld_4661089Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-5\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><hr style=\"width: 100%; float: left;\">\n<div style=\"width: 100%; height: 50px;\"><\/div>\n<h3 style=\"color: #e4032c;\">Klinikam\u0131z\u0131 se\u00e7m\u0259yiniz\u0259 s\u0259b\u0259b<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-6\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_837706\" class=\"form-group\" id=\"fld_837706_1-wrap\">\r\n\t<label id=\"fld_837706Label\" for=\"fld_837706_1\" class=\"control-label screen-reader-text sr-only\">Klinikam\u0131z\u0131 se\u00e7m\u0259yiniz\u0259 s\u0259b\u0259b<\/label>\r\n\t<div class=\"\">\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_837706_1_opt1151281\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_837706_1\" data-parsley-multiple=\"fld_837706_1\"                                type=\"checkbox\"\n                                data-label=\"Klinikadan m\u0259mnun qald\u0131m\"\n                                data-field=\"fld_837706\"\n                                id=\"fld_837706_1_opt1151281\"\n                                class=\"fld_837706_1 option-required\"\n                                name=\"fld_837706[opt1151281]\"\n                                value=\"Klinikadan m\u0259mnun qald\u0131m\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_837706_1\"\n                                                                data-calc-value=\"Klinikadan m\u0259mnun qald\u0131m\"\n                            >\n                    Klinikadan m\u0259mnun qald\u0131m                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_837706_1_opt1666591\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_837706_1\" data-parsley-multiple=\"fld_837706_1\"                                type=\"checkbox\"\n                                data-label=\"H\u0259kimd\u0259n m\u0259mnun qald\u0131m\"\n                                data-field=\"fld_837706\"\n                                id=\"fld_837706_1_opt1666591\"\n                                class=\"fld_837706_1 option-required\"\n                                name=\"fld_837706[opt1666591]\"\n                                value=\"H\u0259kimd\u0259n m\u0259mnun qald\u0131m\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_837706_1\"\n                                                                data-calc-value=\"H\u0259kimd\u0259n m\u0259mnun qald\u0131m\"\n                            >\n                    H\u0259kimd\u0259n m\u0259mnun qald\u0131m                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_837706_1_opt1926930\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_837706_1\" data-parsley-multiple=\"fld_837706_1\"                                type=\"checkbox\"\n                                data-label=\"H\u0259kim g\u00f6nd\u0259ri\u015fi il\u0259\"\n                                data-field=\"fld_837706\"\n                                id=\"fld_837706_1_opt1926930\"\n                                class=\"fld_837706_1 option-required\"\n                                name=\"fld_837706[opt1926930]\"\n                                value=\"H\u0259kim g\u00f6nd\u0259ri\u015fi il\u0259\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_837706_1\"\n                                                                data-calc-value=\"H\u0259kim g\u00f6nd\u0259ri\u015fi il\u0259\"\n                            >\n                    H\u0259kim g\u00f6nd\u0259ri\u015fi il\u0259                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_837706_1_opt1597144\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_837706_1\" data-parsley-multiple=\"fld_837706_1\"                                type=\"checkbox\"\n                                data-label=\" Klinikan\u0131n evim\u0259\/i\u015fim\u0259 yax\u0131n olmas\u0131\"\n                                data-field=\"fld_837706\"\n                                id=\"fld_837706_1_opt1597144\"\n                                class=\"fld_837706_1 option-required\"\n                                name=\"fld_837706[opt1597144]\"\n                                value=\" Klinikan\u0131n evim\u0259\/i\u015fim\u0259 yax\u0131n olmas\u0131\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_837706_1\"\n                                                                data-calc-value=\" Klinikan\u0131n evim\u0259\/i\u015fim\u0259 yax\u0131n olmas\u0131\"\n                            >\n                     Klinikan\u0131n evim\u0259\/i\u015fim\u0259 yax\u0131n olmas\u0131                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_837706_1_opt1459315\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_837706_1\" data-parsley-multiple=\"fld_837706_1\"                                type=\"checkbox\"\n                                data-label=\"F\u0259aliyy\u0259t g\u00f6st\u0259rdiyim m\u00fc\u0259ssis\u0259 v\u0259 ya si\u011forta vasit\u0259si il\u0259\"\n                                data-field=\"fld_837706\"\n                                id=\"fld_837706_1_opt1459315\"\n                                class=\"fld_837706_1 option-required\"\n                                name=\"fld_837706[opt1459315]\"\n                                value=\"F\u0259aliyy\u0259t g\u00f6st\u0259rdiyim m\u00fc\u0259ssis\u0259 v\u0259 ya si\u011forta vasit\u0259si il\u0259\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_837706_1\"\n                                                                data-calc-value=\"F\u0259aliyy\u0259t g\u00f6st\u0259rdiyim m\u00fc\u0259ssis\u0259 v\u0259 ya si\u011forta vasit\u0259si il\u0259\"\n                            >\n                    F\u0259aliyy\u0259t g\u00f6st\u0259rdiyim m\u00fc\u0259ssis\u0259 v\u0259 ya si\u011forta vasit\u0259si il\u0259                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"checkbox\">\n\t\t\t\t\n                <label                         for=\"fld_837706_1_opt1997142\"\n                >\n                            <input\n                                data-parsley-required=\"true\" data-parsley-group=\"fld_837706_1\" data-parsley-multiple=\"fld_837706_1\"                                type=\"checkbox\"\n                                data-label=\"M\u0259tbuat-media vasit\u0259si il\u0259\"\n                                data-field=\"fld_837706\"\n                                id=\"fld_837706_1_opt1997142\"\n                                class=\"fld_837706_1 option-required\"\n                                name=\"fld_837706[opt1997142]\"\n                                value=\"M\u0259tbuat-media vasit\u0259si il\u0259\"\n                                                                data-type=\"checkbox\"\n                                data-checkbox-field=\"fld_837706_1\"\n                                                                data-calc-value=\"M\u0259tbuat-media vasit\u0259si il\u0259\"\n                            >\n                    M\u0259tbuat-media vasit\u0259si il\u0259                <\/label>\n\n                \t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-7\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><hr style=\"width: 100%; float: left;\">\n<div style=\"width: 100%; height: 50px;\"><\/div>\n<h3 style=\"color: #e4032c;\">Qeydiyyat \u015f\u00f6b\u0259si<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-8\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_2537350\" class=\"form-group\" id=\"fld_2537350_1-wrap\">\r\n<label id=\"fld_2537350Label\" for=\"fld_2537350_1\" class=\"control-label\">Q\u0259bul \u015f\u00f6b\u0259si m\u0259n\u0259 qar\u015f\u0131 anlay\u0131\u015fl\u0131 v\u0259 n\u0259zak\u0259tli idi <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_2537350_1_opt909158\"><input type=\"radio\" id=\"fld_2537350_1_opt909158\" data-field=\"fld_2537350\" class=\"fld_2537350_1 option-required\" name=\"fld_2537350\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_2537350_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_2537350_1_opt1606140\"><input type=\"radio\" id=\"fld_2537350_1_opt1606140\" data-field=\"fld_2537350\" class=\"fld_2537350_1 option-required\" name=\"fld_2537350\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_2537350_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_2537350_1_opt2701845\"><input type=\"radio\" id=\"fld_2537350_1_opt2701845\" data-field=\"fld_2537350\" class=\"fld_2537350_1 option-required\" name=\"fld_2537350\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_2537350_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_3872155\" class=\"form-group\" id=\"fld_3872155_1-wrap\">\r\n<label id=\"fld_3872155Label\" for=\"fld_3872155_1\" class=\"control-label\">Q\u0259bul \u015f\u00f6b\u0259si verdiyim suallara dol\u011fun cavab verdi <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_3872155_1_opt66245\"><input type=\"radio\" id=\"fld_3872155_1_opt66245\" data-field=\"fld_3872155\" class=\"fld_3872155_1 option-required\" name=\"fld_3872155\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_3872155_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_3872155_1_opt1169334\"><input type=\"radio\" id=\"fld_3872155_1_opt1169334\" data-field=\"fld_3872155\" class=\"fld_3872155_1 option-required\" name=\"fld_3872155\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_3872155_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_3872155_1_opt2162931\"><input type=\"radio\" id=\"fld_3872155_1_opt2162931\" data-field=\"fld_3872155\" class=\"fld_3872155_1 option-required\" name=\"fld_3872155\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_3872155_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-9\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_323596\" class=\"form-group\" id=\"fld_323596_1-wrap\">\r\n<label id=\"fld_323596Label\" for=\"fld_323596_1\" class=\"control-label\">Qeydiyyat zaman\u0131 h\u0259rhans\u0131 problem ya\u015fand\u0131m\u0131? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_323596_1_opt297555\"><input type=\"radio\" id=\"fld_323596_1_opt297555\" data-field=\"fld_323596\" class=\"fld_323596_1 option-required\" name=\"fld_323596\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_323596_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_323596_1_opt2019747\"><input type=\"radio\" id=\"fld_323596_1_opt2019747\" data-field=\"fld_323596\" class=\"fld_323596_1 option-required\" name=\"fld_323596\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_323596_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_323596_1_opt2857852\"><input type=\"radio\" id=\"fld_323596_1_opt2857852\" data-field=\"fld_323596\" class=\"fld_323596_1 option-required\" name=\"fld_323596\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_323596_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5041324\" class=\"form-group\" id=\"fld_5041324_1-wrap\">\r\n<label id=\"fld_5041324Label\" for=\"fld_5041324_1\" class=\"control-label\">G\u00f6zl\u0259m\u0259k laz\u0131m oldu\u011funda m\u0259n\u0259 bunun s\u0259b\u0259bi haqq\u0131nda m\u0259lumat verildi <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_5041324_1_opt449848\"><input type=\"radio\" id=\"fld_5041324_1_opt449848\" data-field=\"fld_5041324\" class=\"fld_5041324_1 option-required\" name=\"fld_5041324\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_5041324_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_5041324_1_opt1838213\"><input type=\"radio\" id=\"fld_5041324_1_opt1838213\" data-field=\"fld_5041324\" class=\"fld_5041324_1 option-required\" name=\"fld_5041324\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_5041324_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_5041324_1_opt2709123\"><input type=\"radio\" id=\"fld_5041324_1_opt2709123\" data-field=\"fld_5041324\" class=\"fld_5041324_1 option-required\" name=\"fld_5041324\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_5041324_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-10\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><hr style=\"width: 100%; float: left;\">\n<div style=\"width: 100%; height: 50px;\"><\/div>\n<h3 style=\"color: #e4032c;\">H\u0259kim haqq\u0131nda<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-11\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_4036874\" class=\"form-group\" id=\"fld_4036874_1-wrap\">\r\n\t<label id=\"fld_4036874Label\" for=\"fld_4036874_1\" class=\"control-label\">Xidm\u0259t ald\u0131\u011f\u0131n\u0131z h\u0259kim <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"H\u0259kimin ad\u0131, soyad\u0131\"  required type=\"text\" data-field=\"fld_4036874\" class=\" form-control\" id=\"fld_4036874_1\" name=\"fld_4036874\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_4036874Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_8385179\" class=\"form-group\" id=\"fld_8385179_1-wrap\">\r\n\t<label id=\"fld_8385179Label\" for=\"fld_8385179_1\" class=\"control-label\">H\u0259kimin q\u0259buluna d\u00fc\u015fm\u0259k \u00fc\u00e7\u00fcn n\u0259 q\u0259d\u0259r g\u00f6zl\u0259diyinizi dey\u0259 bil\u0259rsinizmi? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n\t<div class=\"\">\r\n\t\t<input placeholder=\"G\u00f6zl\u0259diyiniz m\u00fcdd\u0259ti qeyd edin\"  required type=\"text\" data-field=\"fld_8385179\" class=\" form-control\" id=\"fld_8385179_1\" name=\"fld_8385179\" value=\"\" data-type=\"text\" aria-required=\"true\"   aria-labelledby=\"fld_8385179Label\" >\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-12\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8592801\" class=\"form-group\" id=\"fld_8592801_1-wrap\">\r\n<label id=\"fld_8592801Label\" for=\"fld_8592801_1\" class=\"control-label\">M\u0259ni m\u00fcayin\u0259 ed\u0259n h\u0259kim n\u0259z\u0259k\u0259tli idi <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_8592801_1_opt173619\"><input type=\"radio\" id=\"fld_8592801_1_opt173619\" data-field=\"fld_8592801\" class=\"fld_8592801_1 option-required\" name=\"fld_8592801\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_8592801_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_8592801_1_opt1096901\"><input type=\"radio\" id=\"fld_8592801_1_opt1096901\" data-field=\"fld_8592801\" class=\"fld_8592801_1 option-required\" name=\"fld_8592801\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_8592801_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_8592801_1_opt2855432\"><input type=\"radio\" id=\"fld_8592801_1_opt2855432\" data-field=\"fld_8592801\" class=\"fld_8592801_1 option-required\" name=\"fld_8592801\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_8592801_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5066803\" class=\"form-group\" id=\"fld_5066803_1-wrap\">\r\n<label id=\"fld_5066803Label\" for=\"fld_5066803_1\" class=\"control-label\">X\u0259st\u0259liyim il\u0259 \u0259laq\u0259dar m\u0259ni kifay\u0259t q\u0259d\u0259r dinl\u0259di <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_5066803_1_opt3721\"><input type=\"radio\" id=\"fld_5066803_1_opt3721\" data-field=\"fld_5066803\" class=\"fld_5066803_1 option-required\" name=\"fld_5066803\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_5066803_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_5066803_1_opt1923562\"><input type=\"radio\" id=\"fld_5066803_1_opt1923562\" data-field=\"fld_5066803\" class=\"fld_5066803_1 option-required\" name=\"fld_5066803\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_5066803_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_5066803_1_opt2630485\"><input type=\"radio\" id=\"fld_5066803_1_opt2630485\" data-field=\"fld_5066803\" class=\"fld_5066803_1 option-required\" name=\"fld_5066803\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_5066803_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-13\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_903236\" class=\"form-group\" id=\"fld_903236_1-wrap\">\r\n<label id=\"fld_903236Label\" for=\"fld_903236_1\" class=\"control-label\">Diaqnoz qoyduqdan sonra m\u0259n\u0259 m\u00fcalic\u0259 bar\u0259d\u0259 \u0259trafl\u0131 m\u0259lumat verdi <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_903236_1_opt136148\"><input type=\"radio\" id=\"fld_903236_1_opt136148\" data-field=\"fld_903236\" class=\"fld_903236_1 option-required\" name=\"fld_903236\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_903236_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_903236_1_opt1449022\"><input type=\"radio\" id=\"fld_903236_1_opt1449022\" data-field=\"fld_903236\" class=\"fld_903236_1 option-required\" name=\"fld_903236\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_903236_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_903236_1_opt2397787\"><input type=\"radio\" id=\"fld_903236_1_opt2397787\" data-field=\"fld_903236\" class=\"fld_903236_1 option-required\" name=\"fld_903236\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_903236_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-14\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><hr style=\"width: 100%; float: left;\">\n<div style=\"width: 100%; height: 50px;\"><\/div>\n<h3 style=\"color: #e4032c;\">Tibbi personal<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-15\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_5012152\" class=\"form-group\" id=\"fld_5012152_1-wrap\">\r\n<label id=\"fld_5012152Label\" for=\"fld_5012152_1\" class=\"control-label\">Tibb bac\u0131lar\u0131n\u0131n davran\u0131n\u0131\u015f\u0131 b\u0259y\u0259ndim <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_5012152_1_opt281782\"><input type=\"radio\" id=\"fld_5012152_1_opt281782\" data-field=\"fld_5012152\" class=\"fld_5012152_1 option-required\" name=\"fld_5012152\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_5012152_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_5012152_1_opt1682399\"><input type=\"radio\" id=\"fld_5012152_1_opt1682399\" data-field=\"fld_5012152\" class=\"fld_5012152_1 option-required\" name=\"fld_5012152\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_5012152_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_5012152_1_opt2643078\"><input type=\"radio\" id=\"fld_5012152_1_opt2643078\" data-field=\"fld_5012152\" class=\"fld_5012152_1 option-required\" name=\"fld_5012152\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_5012152_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_6421720\" class=\"form-group\" id=\"fld_6421720_1-wrap\">\r\n<label id=\"fld_6421720Label\" for=\"fld_6421720_1\" class=\"control-label\">Tibb bac\u0131s\u0131n\u0131n g\u00f6st\u0259rdiyi xidm\u0259td\u0259n(qan alma,inyeksiya,m\u00fcayin\u0259y\u0259 haz\u0131rlama v\u0259 s.) raz\u0131 qald\u0131m <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_6421720_1_opt1012648\"><input type=\"radio\" id=\"fld_6421720_1_opt1012648\" data-field=\"fld_6421720\" class=\"fld_6421720_1 option-required\" name=\"fld_6421720\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_6421720_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_6421720_1_opt1471733\"><input type=\"radio\" id=\"fld_6421720_1_opt1471733\" data-field=\"fld_6421720\" class=\"fld_6421720_1 option-required\" name=\"fld_6421720\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_6421720_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_6421720_1_opt2815515\"><input type=\"radio\" id=\"fld_6421720_1_opt2815515\" data-field=\"fld_6421720\" class=\"fld_6421720_1 option-required\" name=\"fld_6421720\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_6421720_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-16\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><hr style=\"width: 100%; float: left;\">\n<div style=\"width: 100%; height: 50px;\"><\/div>\n<h3 style=\"color: #e4032c;\">Laboratoriya v\u0259 instrumental diaqnostika<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-17\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_355121\" class=\"form-group\" id=\"fld_355121_1-wrap\">\r\n<label id=\"fld_355121Label\" for=\"fld_355121_1\" class=\"control-label\">Tibbi g\u00f6r\u00fcnt\u00fcl\u0259m\u0259 (USM,Radiologiya,KT,EKG,EXO,Endoskopiya) xidm\u0259tl\u0259rind\u0259n raz\u0131 qald\u0131m <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_355121_1_opt193611\"><input type=\"radio\" id=\"fld_355121_1_opt193611\" data-field=\"fld_355121\" class=\"fld_355121_1 option-required\" name=\"fld_355121\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_355121_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_355121_1_opt1461692\"><input type=\"radio\" id=\"fld_355121_1_opt1461692\" data-field=\"fld_355121\" class=\"fld_355121_1 option-required\" name=\"fld_355121\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_355121_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_355121_1_opt2946901\"><input type=\"radio\" id=\"fld_355121_1_opt2946901\" data-field=\"fld_355121\" class=\"fld_355121_1 option-required\" name=\"fld_355121\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_355121_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_1760808\" class=\"form-group\" id=\"fld_1760808_1-wrap\">\r\n<label id=\"fld_1760808Label\" for=\"fld_1760808_1\" class=\"control-label\">Laborator n\u0259tic\u0259l\u0259rin verilm\u0259sind\u0259 gecikm\u0259 oldumu? <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_1760808_1_opt981215\"><input type=\"radio\" id=\"fld_1760808_1_opt981215\" data-field=\"fld_1760808\" class=\"fld_1760808_1 option-required\" name=\"fld_1760808\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_1760808_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_1760808_1_opt1338531\"><input type=\"radio\" id=\"fld_1760808_1_opt1338531\" data-field=\"fld_1760808\" class=\"fld_1760808_1 option-required\" name=\"fld_1760808\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_1760808_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_1760808_1_opt3083833\"><input type=\"radio\" id=\"fld_1760808_1_opt3083833\" data-field=\"fld_1760808\" class=\"fld_1760808_1 option-required\" name=\"fld_1760808\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_1760808_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-18\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_8714267\" class=\"form-group\" id=\"fld_8714267_1-wrap\">\r\n<label id=\"fld_8714267Label\" for=\"fld_8714267_1\" class=\"control-label\">M\u0259ni m\u00fcalic\u0259 ed\u0259n (g\u00f6nd\u0259r\u0259n) h\u0259kim laborator n\u0259tic\u0259l\u0259rd\u0259n raz\u0131 qald\u0131 (cavab\u0131 g\u00f6rd\u00fckd\u0259n sonra) <span aria-hidden=\"true\" role=\"presentation\" class=\"field_required\" style=\"color:#ee0000;\">*<\/span><\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_8714267_1_opt744577\"><input type=\"radio\" id=\"fld_8714267_1_opt744577\" data-field=\"fld_8714267\" class=\"fld_8714267_1 option-required\" name=\"fld_8714267\" value=\"B\u0259li\"   required=\"required\" data-radio-field=\"fld_8714267_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_8714267_1_opt1655042\"><input type=\"radio\" id=\"fld_8714267_1_opt1655042\" data-field=\"fld_8714267\" class=\"fld_8714267_1 option-required\" name=\"fld_8714267\" value=\"Xeyr\"   required=\"required\" data-radio-field=\"fld_8714267_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_8714267_1_opt2348561\"><input type=\"radio\" id=\"fld_8714267_1_opt2348561\" data-field=\"fld_8714267\" class=\"fld_8714267_1 option-required\" name=\"fld_8714267\" value=\"Fikrim yoxdur\"   required=\"required\" data-radio-field=\"fld_8714267_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-19\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><hr style=\"width: 100%; float: left;\">\n<div style=\"width: 100%; height: 50px;\"><\/div>\n<h3 style=\"color: #e4032c;\">X\u0259st\u0259xanan\u0131n \u00fcmumi v\u0259ziyy\u0259ti<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-20\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_1305982\" class=\"form-group\" id=\"fld_1305982_1-wrap\">\r\n<label id=\"fld_1305982Label\" for=\"fld_1305982_1\" class=\"control-label\">Poliklinikalar(m\u00fcayin\u0259 edildiyiniz otaq,g\u00f6zl\u0259m\u0259 zal\u0131,d\u0259hliz,tuaet)t\u0259miz idi?<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_1305982_1_opt1379435\"><input type=\"radio\" id=\"fld_1305982_1_opt1379435\" data-field=\"fld_1305982\" class=\"fld_1305982_1\" name=\"fld_1305982\" value=\"B\u0259li\"    data-radio-field=\"fld_1305982_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_1305982_1_opt1863671\"><input type=\"radio\" id=\"fld_1305982_1_opt1863671\" data-field=\"fld_1305982\" class=\"fld_1305982_1\" name=\"fld_1305982\" value=\"Xeyr\"    data-radio-field=\"fld_1305982_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_1305982_1_opt1472220\"><input type=\"radio\" id=\"fld_1305982_1_opt1472220\" data-field=\"fld_1305982\" class=\"fld_1305982_1\" name=\"fld_1305982\" value=\"Fikrim yoxdur\"    data-radio-field=\"fld_1305982_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_7382303\" class=\"form-group\" id=\"fld_7382303_1-wrap\">\r\n<label id=\"fld_7382303Label\" for=\"fld_7382303_1\" class=\"control-label\">Bufet xidm\u0259tl\u0259rind\u0259n raz\u0131 qald\u0131m<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_7382303_1_opt1128049\"><input type=\"radio\" id=\"fld_7382303_1_opt1128049\" data-field=\"fld_7382303\" class=\"fld_7382303_1\" name=\"fld_7382303\" value=\"B\u0259li\"    data-radio-field=\"fld_7382303_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_7382303_1_opt1608511\"><input type=\"radio\" id=\"fld_7382303_1_opt1608511\" data-field=\"fld_7382303\" class=\"fld_7382303_1\" name=\"fld_7382303\" value=\"Xeyr\"    data-radio-field=\"fld_7382303_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_7382303_1_opt1204795\"><input type=\"radio\" id=\"fld_7382303_1_opt1204795\" data-field=\"fld_7382303\" class=\"fld_7382303_1\" name=\"fld_7382303\" value=\"Fikrim yoxdur\"    data-radio-field=\"fld_7382303_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-21\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_1598423\" class=\"form-group\" id=\"fld_1598423_1-wrap\">\r\n<label id=\"fld_1598423Label\" for=\"fld_1598423_1\" class=\"control-label\">X\u0259st\u0259xana daxili y\u00f6nl\u0259ndirici tablolar yax\u015f\u0131 t\u0259\u015fkil olunmu\u015fdu<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_1598423_1_opt1754244\"><input type=\"radio\" id=\"fld_1598423_1_opt1754244\" data-field=\"fld_1598423\" class=\"fld_1598423_1\" name=\"fld_1598423\" value=\"B\u0259li\"    data-radio-field=\"fld_1598423_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_1598423_1_opt1143480\"><input type=\"radio\" id=\"fld_1598423_1_opt1143480\" data-field=\"fld_1598423\" class=\"fld_1598423_1\" name=\"fld_1598423\" value=\"Xeyr\"    data-radio-field=\"fld_1598423_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_1598423_1_opt1428513\"><input type=\"radio\" id=\"fld_1598423_1_opt1428513\" data-field=\"fld_1598423\" class=\"fld_1598423_1\" name=\"fld_1598423\" value=\"Fikrim yoxdur\"    data-radio-field=\"fld_1598423_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_919594\" class=\"form-group\" id=\"fld_919594_1-wrap\">\r\n<label id=\"fld_919594Label\" for=\"fld_919594_1\" class=\"control-label\">Z\u0259ng m\u0259rk\u0259zinin xidm\u0259tl\u0259rind\u0259n raz\u0131 qald\u0131m<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_919594_1_opt1598026\"><input type=\"radio\" id=\"fld_919594_1_opt1598026\" data-field=\"fld_919594\" class=\"fld_919594_1\" name=\"fld_919594\" value=\"B\u0259li\"    data-radio-field=\"fld_919594_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_919594_1_opt1196605\"><input type=\"radio\" id=\"fld_919594_1_opt1196605\" data-field=\"fld_919594\" class=\"fld_919594_1\" name=\"fld_919594\" value=\"Xeyr\"    data-radio-field=\"fld_919594_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxudr\" for=\"fld_919594_1_opt1431415\"><input type=\"radio\" id=\"fld_919594_1_opt1431415\" data-field=\"fld_919594\" class=\"fld_919594_1\" name=\"fld_919594\" value=\"Fikrim yoxudr\"    data-radio-field=\"fld_919594_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxudr\" \/>\n\t\t\tFikrim yoxudr\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-22\"  class=\"row \"><div  class=\"col-sm-6  first_col\"><div data-field-wrapper=\"fld_180859\" class=\"form-group\" id=\"fld_180859_1-wrap\">\r\n<label id=\"fld_180859Label\" for=\"fld_180859_1\" class=\"control-label\">Avto dayanacaq xidm\u0259tind\u0259n raz\u0131 qald\u0131m<\/label>\r\n<div class=\"\">\r\n\t\t\t\t<label class=\"radio-inline\" data-label=\"B\u0259li\" for=\"fld_180859_1_opt1128350\"><input type=\"radio\" id=\"fld_180859_1_opt1128350\" data-field=\"fld_180859\" class=\"fld_180859_1\" name=\"fld_180859\" value=\"B\u0259li\"    data-radio-field=\"fld_180859_1\" data-type=\"radio\" data-calc-value=\"B\u0259li\" \/>\n\t\t\tB\u0259li\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Xeyr\" for=\"fld_180859_1_opt1601264\"><input type=\"radio\" id=\"fld_180859_1_opt1601264\" data-field=\"fld_180859\" class=\"fld_180859_1\" name=\"fld_180859\" value=\"Xeyr\"    data-radio-field=\"fld_180859_1\" data-type=\"radio\" data-calc-value=\"Xeyr\" \/>\n\t\t\tXeyr\t\t<\/label>\n\t\t\t\t\t\t\t\t<label class=\"radio-inline\" data-label=\"Fikrim yoxdur\" for=\"fld_180859_1_opt1837647\"><input type=\"radio\" id=\"fld_180859_1_opt1837647\" data-field=\"fld_180859\" class=\"fld_180859_1\" name=\"fld_180859\" value=\"Fikrim yoxdur\"    data-radio-field=\"fld_180859_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><div  class=\"col-sm-6  last_col\"><div data-field-wrapper=\"fld_5009481\" class=\"form-group\" id=\"fld_5009481_1-wrap\">\r\n<label id=\"fld_5009481Label\" for=\"fld_5009481_1\" class=\"control-label\">X\u0259st\u0259xanada \u00fcmumi \u015f\u0259kild\u0259 g\u00f6st\u0259ril\u0259n xidm\u0259tin keyfiyy\u0259ti y\u00fcks\u0259k 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value=\"Fikrim yoxdur\"    data-radio-field=\"fld_5009481_1\" data-type=\"radio\" data-calc-value=\"Fikrim yoxdur\" \/>\n\t\t\tFikrim yoxdur\t\t<\/label>\n\t\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-23\"  class=\"row \"><div  class=\"col-sm-12  single\"><div class=\"\"><hr style=\"width: 100%; float: left;\">\n<div style=\"width: 100%; height: 50px;\"><\/div>\n<h3 style=\"color: #e4032c;\">\u018flav\u0259 qeydl\u0259riniz v\u0259 t\u0259klifl\u0259riniz<\/h3>\n<hr style=\"width: 400px; float: left;\">\n<div style=\"width: 100%; height: 30px;\"><\/div>\n<\/div><\/div><\/div><div id=\"CF5cd2875938ffa_1-row-24\"  class=\"row \"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_341135\" class=\"form-group\" id=\"fld_341135_1-wrap\">\r\n\t<label id=\"fld_341135Label\" for=\"fld_341135_1\" class=\"control-label screen-reader-text sr-only\">Qeydl\u0259riniz v\u0259 t\u0259klifl\u0259riniz<\/label>\r\n\t<div class=\"\">\r\n\t\t<textarea name=\"fld_341135\" value=\"\" data-field=\"fld_341135\" class=\"form-control\" id=\"fld_341135_1\" rows=\"8\" placeholder=\"Qeydl\u0259riniz v\u0259 t\u0259klifl\u0259riniz\"    aria-labelledby=\"fld_341135Label\" ><\/textarea>\n\t\t\t<\/div>\r\n<\/div>\r\n<\/div><\/div><div id=\"CF5cd2875938ffa_1-row-25\"  class=\"row  last_row\"><div  class=\"col-sm-12  single\"><div data-field-wrapper=\"fld_8698348\" class=\"form-group\" id=\"fld_8698348_1-wrap\">\r\n\t<label class=\"control-label\">&nbsp;<\/label>\n<div class=\"\">\r\n\t<input  class=\"btn btn-default\" type=\"submit\" name=\"fld_8698348\" id=\"fld_8698348_1\" value=\"Anketi g\u00f6nd\u0259r\" data-field=\"fld_8698348\"  >\n<\/div>\r\n<\/div>\r\n\t<input class=\"button_trigger_1\" type=\"hidden\" name=\"fld_8698348\" id=\"fld_8698348_1_btn\" value=\"\" data-field=\"fld_8698348\"  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