{"id":33893,"date":"2019-08-14T09:28:20","date_gmt":"2019-08-14T09:28:20","guid":{"rendered":"https:\/\/babszorg.com\/EN\/?page_id=33893"},"modified":"2019-08-20T04:09:19","modified_gmt":"2019-08-20T04:09:19","slug":"palliative-care-application-form","status":"publish","type":"page","link":"https:\/\/babszorg.com\/babszorg.com\/EN\/palliative-care-application-form\/","title":{"rendered":"Palliative care Application Form"},"content":{"rendered":"<p>[et_pb_section bb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;3.21.1&#8243; custom_margin=&#8221;||0px&#8221; custom_padding=&#8221;||0px&#8221; z_index_tablet=&#8221;500&#8243; locked=&#8221;off&#8221; next_background_color=&#8221;#000000&#8243;][et_pb_fullwidth_header admin_label=&#8221;Palliative care Application Form&#8221; title=&#8221;Palliative care Application Form&#8221; _builder_version=&#8221;3.21.1&#8243; background_color=&#8221;#00A79D&#8221; background_image=&#8221;https:\/\/babszorg.com\/babszorg.com\/EN\/wp-content\/uploads\/2019\/07\/inner-bgimage.jpg&#8221; background_blend=&#8221;overlay&#8221; z_index_tablet=&#8221;500&#8243; \/][\/et_pb_section][et_pb_section bb_built=&#8221;1&#8243; _builder_version=&#8221;3.21.1&#8243; prev_background_color=&#8221;#000000&#8243; next_background_color=&#8221;#78A22F&#8221;][et_pb_row use_custom_gutter=&#8221;on&#8221; gutter_width=&#8221;2&#8243; custom_padding=&#8221;2px|0px|27px|0px|false|false&#8221; background_color_2=&#8221;#f4f4f4&#8243; _builder_version=&#8221;3.21.1&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; module_alignment=&#8221;center&#8221;][et_pb_column type=&#8221;3_4&#8243;][et_pb_text _builder_version=&#8221;3.21.1&#8243; text_font_size=&#8221;15px&#8221; z_index_tablet=&#8221;500&#8243;]<\/p>\n<h2>Palliative care Application Form<\/h2>\n<p>Palliative care is care that is given to clients when it is no longer possible to cure a disease. Then you can think of cancer when it has been treated. But dementia, COPD or heart failure are diseases that people cannot cure. With these diseases you can live for weeks, months or even years.<\/p>\n<p>Because someone is no longer able to heal and still lives with this disease for a (long) time, the primary goal of palliative care is to maintain and, where possible, improve the quality of life of the client. In palliative care, attention is paid to physical, social, psychological and spiritual dimensions. In addition, supporting relatives is also an important part of palliative care.<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;3.21.1&#8243;]<\/p>\n<div id=\"erf_form_container_33891\" class=\"erf-container erf-label-inline erf-layout-one-column erf-style-rounded-corner  \">\n        <div class=\"erf-reg-form-container\" style=\"\">\n            \n        \n             \n                            <div class=\"erf-content-above\">\n                                    <\/div>\n                <form method=\"post\" enctype=\"multipart\/form-data\" class=\"erf-form erf-front-form\" data-parsley-validate=\"\" novalidate=\"true\" autocomplete=\"off\" data-erf-submission-id=\"0\" data-erf-form-id=\"33891\">\n                    <div class=\"erf-form-html\" id=\"erf_form_33891\">\n                        <div class=\"rendered-form\">\n                        <div class=\"erf-header erf-element-width-12\"><h1  data-non-input='1' data-ref-id='ref-6xcv1m4rp1x' data-ref-label='ref-em6v2' class='' >Arrange for Palliatieve care\u00a0<\/h1><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' class='bline' data-ref-id='ref-dxsw3p0zio6' data-ref-label='ref-y3t1dp' >Contact details<\/h4><\/div><div class=\"erf-radio-group form-group field-radio-group-1564122470936 erf-element-width-12\"><label for=\"radio-group-1564122470936\" class=\"erf-radio-group-label\">Gender<span class=\"erf-required\">*<\/span><\/label><div class=\"radio-group\"><div class=\"radio-inline\"><input id=\"radio-group-1564122470936-0\" required='required' name='radio-group-1564122470936' class='form-control'  type=\"radio\" value=\"Man\" \/><label for=\"radio-group-1564122470936-0\">Man<\/label><\/div><div class=\"radio-inline\"><input id=\"radio-group-1564122470936-1\" required='required' name='radio-group-1564122470936' class='form-control'  type=\"radio\" value=\"Woman\" \/><label for=\"radio-group-1564122470936-1\">Woman<\/label><\/div><\/div><\/div><div class=\"erf-text form-group field-text-1561624905272 erf-element-width-12\"><label for=\"text-1561624905272\" class=\"erf-text-label\">Initials<span class=\"erf-required\">*<\/span><\/label><input type='text' required='required' class='form-control' name='text-1561624905272' id='text-1561624905272'  \/><\/div><div class=\"erf-text form-group field-text-BzW1kf erf-element-width-12\"><label for=\"text-BzW1kf\" class=\"erf-text-label\">Surname<span class=\"erf-required\">*<\/span><\/label><input type='text' required='required' class='form-control' name='text-BzW1kf' id='text-BzW1kf'  \/><\/div><div class=\"erf-text form-group field-date-1555598217730 erf-element-width-12\"><label for=\"date-1555598217730\" class=\"erf-text-label\">Date of birth<span class=\"erf-required\">*<\/span><\/label><input type='text' required='required' data-date-format='mm\/dd\/yy' class='form-control erf-date-field' name='date-1555598217730' id='date-1555598217730'  \/><\/div><div class=\"erf-email form-group field-text-HNLfNN erf-element-width-12\"><label for=\"text-HNLfNN\" class=\"erf-email-label\">E-mail addres<span class=\"erf-required\">*<\/span><\/label><input type='email' required='1' class='form-control' name='text-HNLfNN' id='text-HNLfNN'  \/><\/div><div class=\"erf-street1 form-group field-text-1553340722373 erf-element-width-12\"><label for=\"text-1553340722373\" class=\"erf-street1-label\">Street name and house number<span class=\"erf-required\">*<\/span><\/label><input type='street1' required='required' class='form-control' name='text-1553340722373' id='text-1553340722373'  \/><\/div><div class=\"erf-zip form-group field-text-1553340722491 erf-element-width-12\"><label for=\"text-1553340722491\" class=\"erf-zip-label\">Postcode<span class=\"erf-required\">*<\/span><\/label><input type='zip' required='required' class='form-control' name='text-1553340722491' id='text-1553340722491'  \/><\/div><div class=\"erf-city form-group field-text-1553340722314 erf-element-width-12\"><label for=\"text-1553340722314\" class=\"erf-city-label\">City\/Town<span class=\"erf-required\">*<\/span><\/label><input type='city' required='required' class='form-control' name='text-1553340722314' id='text-1553340722314'  \/><\/div><div class=\"erf-checkbox-group form-group field-checkbox-group-1564122974725 erf-element-width-12\"><label for=\"checkbox-group-1564122974725\" class=\"erf-checkbox-group-label\">Is there a contact person?<\/label><div class=\"checkbox-group\"><div class=\"checkbox-inline\"><input id=\"checkbox-group-1564122974725-0\" name='checkbox-group-1564122974725[]' class='form-control'  type=\"checkbox\" value=\"Yes\" \/><label for=\"checkbox-group-1564122974725-0\">Yes<\/label><\/div><div class=\"checkbox-inline\"><input id=\"checkbox-group-1564122974725-1\" name='checkbox-group-1564122974725[]' class='form-control'  type=\"checkbox\" value=\"No\" \/><label for=\"checkbox-group-1564122974725-1\">No<\/label><\/div><\/div><\/div><div class=\"erf-text form-group field-text-1555330523970 erf-element-width-12\"><label for=\"text-1555330523970\" class=\"erf-text-label\">Yes. Please give details about the contact person.<\/label><input type='text' class='form-control' name='text-1555330523970' id='text-1555330523970'  \/><\/div><div class=\"erf-text form-group field-text-1564123565447 erf-element-width-12\"><label for=\"text-1564123565447\" class=\"erf-text-label\">Adress contact person<\/label><input type='text' class='form-control' name='text-1564123565447' id='text-1564123565447'  \/><\/div><div class=\"erf-text form-group field-text-1564123342459 erf-element-width-12\"><label for=\"text-1564123342459\" class=\"erf-text-label\">Relationship between patient and contact person<\/label><input type='text' class='form-control' name='text-1564123342459' id='text-1564123342459'  \/><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' class='bline' data-ref-id='ref-dxsw3p0zio6' data-ref-label='ref-y3t1dp' >Your indication<\/h4><\/div><div class=\"erf-checkbox-group form-group field-checkbox-group-1564123672470 erf-element-width-12\"><label for=\"checkbox-group-1564123672470\" class=\"erf-checkbox-group-label\">Checkbox Group<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"checkbox-group-1564123672470-0\" name='checkbox-group-1564123672470[]' class='form-control'  type=\"checkbox\" value=\"You have CIZ indication\" \/><label for=\"checkbox-group-1564123672470-0\">You have CIZ indication<\/label><\/div><div class=\"checkbox\"><input id=\"checkbox-group-1564123672470-1\" name='checkbox-group-1564123672470[]' class='form-control'  type=\"checkbox\" value=\"You have WMO indication\" \/><label for=\"checkbox-group-1564123672470-1\">You have WMO indication<\/label><\/div><div class=\"checkbox\"><input id=\"checkbox-group-1564123672470-2\" name='checkbox-group-1564123672470[]' class='form-control'  type=\"checkbox\" value=\"You have applied for CIZ indication\" \/><label for=\"checkbox-group-1564123672470-2\">You have applied for CIZ indication<\/label><\/div><div class=\"checkbox\"><input id=\"checkbox-group-1564123672470-3\" name='checkbox-group-1564123672470[]' class='form-control'  type=\"checkbox\" value=\"You have applied for WMO indication\" \/><label for=\"checkbox-group-1564123672470-3\">You have applied for WMO indication<\/label><\/div><\/div><\/div><div class=\"erf-textarea form-group field-textarea-1555612030284 erf-element-width-12\"><label for=\"textarea-1555612030284\" class=\"erf-textarea-label\">Name Insurance provider<span class=\"erf-required\">*<\/span><\/label><textarea required='required' class='form-control' name='textarea-1555612030284' id='textarea-1555612030284' ><\/textarea><\/div><div class=\"erf-checkbox-group form-group field-checkbox-group-1564124105956 erf-element-width-12\"><label for=\"checkbox-group-1564124105956\" class=\"erf-checkbox-group-label\">Which PGB are you linked to?<\/label><div class=\"checkbox-group\"><div class=\"checkbox\"><input id=\"checkbox-group-1564124105956-0\" name='checkbox-group-1564124105956[]' class='form-control'  type=\"checkbox\" value=\"U heeft een CIZ indicatie\" \/><label for=\"checkbox-group-1564124105956-0\">Pgb uit Wet langdurige zorg (Wlz):<\/label><\/div><div class=\"checkbox\"><input id=\"checkbox-group-1564124105956-1\" name='checkbox-group-1564124105956[]' class='form-control'  type=\"checkbox\" value=\"U heeft een WMO indicatie\" \/><label for=\"checkbox-group-1564124105956-1\">Pgb uit Wet maatschappelijke ondersteuning (Wmo):0<\/label><\/div><div class=\"checkbox\"><input id=\"checkbox-group-1564124105956-2\" name='checkbox-group-1564124105956[]' class='form-control'  type=\"checkbox\" value=\"U heeft een CIZ indicatie aangevraagd\" \/><label for=\"checkbox-group-1564124105956-2\">Pgb uit Wet maatschappelijke ondersteuning (Wmo):0<\/label><\/div><div class=\"checkbox\"><input id=\"checkbox-group-1564124105956-3\" name='checkbox-group-1564124105956[]' class='form-control'  type=\"checkbox\" value=\"U heeft een WMO indicatie aangevraagd\" \/><label for=\"checkbox-group-1564124105956-3\">Pgb uit de Zorgverzekeringswet (Zvw):<\/label><\/div><\/div><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' class='bline' data-ref-id='ref-dxsw3p0zio6' data-ref-label='ref-y3t1dp' >Your healthcare request<\/h4><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' class='para' data-ref-id='ref-dxsw3p0zio6' data-ref-label='ref-zgvkuh' >Palliative care is not intended to cure the patient. This care is applied when the patient can no longer heal. The goal, however, is to give the patient a long life with a good quality of life. This goes according to the patient's own wishes and choices. An attempt is made to prevent inconveniences and to alleviate complaints.<\/h4><\/div><div class=\"erf-header erf-element-width-12\"><h4  data-non-input='1' class='para' data-ref-id='ref-dxsw3p0zio6' data-ref-label='ref-zgvkuh' >Important topics that have to do with palliative care are: Quality of life of the client. This includes the wishes and needs of the client and loved ones. Dealing with symptoms (symptom management). Making agreements and joint decision-making. The wishes, ideas and decisions of the client (autonomy of the client \/ freedom of the client to make decisions). The care is provided by different care providers who work together (integrated and multidimensional approach). Healthcare is also aimed at relatives. It is often drastic for the client's environment when their loved one is sick and can no longer get better.<\/h4><\/div><div class=\"erf-textarea form-group field-textarea-1555598789291 erf-element-width-12\"><label for=\"textarea-1555598789291\" class=\"erf-textarea-label\">Remarks \/ Special requests<\/label><textarea class='form-control' name='textarea-1555598789291' id='textarea-1555598789291' ><\/textarea><\/div><div class=\"erf-button form-group field-button-f7k3WF erf-element-width-12\"><button type='submit'class='btn btn-primary'name='button-f7k3WF'data-erf-btn-pos='center'id='button-f7k3WF'>Send<\/button><\/div><div class=\"erf-password form-group field-text-zZv4Wr erf-element-width-12\"><label for=\"text-zZv4Wr\" class=\"erf-password-label\">.<span class=\"erf-required\">*<\/span><\/label><input type='password' class='pass-hide' name='text-zZv4Wr' id='text-zZv4Wr'  \/><\/div>                        <\/div>    \n                    <\/div>   \n\n                    <div class=\"erf-external-form-elements\">\n                        \n                        \n\n                        \n                        \n                                                    <!-- Show reCaptcha if configured -->\n                                                                    <div class=\"g-recaptcha erf-recaptcha clearfix\" data-sitekey=\"6LcyisEUAAAAAJZ-QZLZKgolFCDQwJe2EHcqcAks\"><\/div>\n                                    \n                            <!-- reCaptcha ends here -->\n                                                <div class=\"erf-errors\" style=\"display:none\">\n                            <span class=\"erf-errors-head erf-error-row\">Error occured. 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text-decoration: underline;%22> <a style=%22color: #ffffff; text-decoration: underline;%22 href=%22https:\/\/babszorg.com\/babszorg.com\/EN\/privacy-policy-2\/%22>Privacy policy<\/a><\/span><\/span> here.&#8221; form_field_background_color=&#8221;rgba(255,255,255,0.2)&#8221; form_field_text_color=&#8221;#ffffff&#8221; focus_text_color=&#8221;#ffffff&#8221; _builder_version=&#8221;3.21.1&#8243; header_font_size=&#8221;24px&#8221; use_background_color=&#8221;off&#8221; custom_button=&#8221;on&#8221; button_bg_color=&#8221;#78a22f&#8221; z_index_tablet=&#8221;500&#8243; button_border_width__hover_enabled=&#8221;on&#8221; button_border_width__hover=&#8221;2px&#8221; \/][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section bb_built=&#8221;1&#8243; specialty=&#8221;on&#8221; _builder_version=&#8221;3.21.1&#8243; background_image=&#8221;https:\/\/babszorg.com\/babszorg.com\/EN\/wp-content\/uploads\/2019\/05\/babszorg-referentie-bg-2.jpg&#8221; custom_padding=&#8221;54px|1px|29px|0px|false|false&#8221; 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