{"id":15588,"date":"2026-01-08T13:25:13","date_gmt":"2026-01-08T13:25:13","guid":{"rendered":"https:\/\/balsam-medica.pl\/pl\/?page_id=15588"},"modified":"2026-01-08T13:34:10","modified_gmt":"2026-01-08T13:34:10","slug":"formularz-zgloszeniowy","status":"publish","type":"page","link":"https:\/\/balsam-medica.pl\/pl\/formularz-zgloszeniowy\/","title":{"rendered":"Formularz zg\u0142oszeniowy"},"content":{"rendered":"<div id=\"cmsmasters_row_2ew1duqgmb\" class=\"cmsmasters_row cmsmasters_color_scheme_default cmsmasters_row_top_default cmsmasters_row_bot_default cmsmasters_row_fullwidth\">\n<div class=\"cmsmasters_row_outer_parent\">\n<div class=\"cmsmasters_row_outer\">\n<div class=\"cmsmasters_row_inner cmsmasters_row_fullwidth\">\n<div class=\"cmsmasters_row_margin\">\n<div id=\"cmsmasters_column_iffzaut8bf\" class=\"cmsmasters_column one_first\">\n<div class=\"cmsmasters_column_inner\">\n<div class=\"cmsmasters_slider\">\n\t\t\t<!-- START slider About Us REVOLUTION SLIDER 6.6.15 --><p class=\"rs-p-wp-fix\"><\/p>\n\t\t\t<rs-module-wrap id=\"rev_slider_3_1_wrapper\" data-source=\"gallery\" style=\"visibility:hidden;background:transparent;padding:0;margin:0px auto;margin-top:0;margin-bottom:0;\">\n\t\t\t\t<rs-module id=\"rev_slider_3_1\" style=\"\" data-version=\"6.6.15\">\n\t\t\t\t\t<rs-slides style=\"overflow: hidden; position: absolute;\">\n\t\t\t\t\t\t<rs-slide style=\"position: absolute;\" data-key=\"rs-12\" data-title=\"Slide\" data-in=\"o:0;\" data-out=\"a:false;\">\n\t\t\t\t\t\t\t<img decoding=\"async\" src=\"\/\/balsam-medica.pl\/wp-content\/plugins\/revslider\/public\/assets\/assets\/dummy.png\" alt=\"Slide\" title=\"Portrait of smiling doctor in white uniform standing with crossed hands on grey background\" width=\"2560\" height=\"1706\" class=\"rev-slidebg tp-rs-img rs-lazyload\" data-lazyload=\"\/\/balsam-medica.pl\/wp-content\/plugins\/revslider\/public\/assets\/assets\/transparent.png\" data-bg=\"p:right top;c:linear-gradient(rgba(52,59,66,1) 0%, rgba(92,111,117,1) 100%);\" data-no-retina>\n<!--\n\t\t\t\t\t\t\t--><rs-layer\n\t\t\t\t\t\t\t\tid=\"slider-3-slide-12-layer-0\" \n\t\t\t\t\t\t\t\tdata-type=\"image\"\n\t\t\t\t\t\t\t\tdata-rsp_ch=\"on\"\n\t\t\t\t\t\t\t\tdata-xy=\"xo:11px,11px,11px,1px;yo:-131px,-131px,-131px,-32px;\"\n\t\t\t\t\t\t\t\tdata-text=\"w:normal;s:20,20,20,4;l:0,0,0,6;\"\n\t\t\t\t\t\t\t\tdata-dim=\"w:1920px,1920px,1920px,480px;h:1280px,1280px,1280px,319px;\"\n\t\t\t\t\t\t\t\tdata-frame_1=\"sp:1040;\"\n\t\t\t\t\t\t\t\tdata-frame_999=\"o:0;st:w;sR:1960;\"\n\t\t\t\t\t\t\t\tstyle=\"z-index:6;\"\n\t\t\t\t\t\t\t><img decoding=\"async\" src=\"\/\/balsam-medica.pl\/wp-content\/plugins\/revslider\/public\/assets\/assets\/dummy.png\" alt=\"\" class=\"tp-rs-img rs-lazyload\" width=\"2560\" height=\"1707\" data-lazyload=\"\/\/balsam-medica.pl\/wp-content\/uploads\/2023\/10\/IMG_8710-2-kopia-scaled.jpg\" data-no-retina> \n\t\t\t\t\t\t\t<\/rs-layer><!--\n\n\t\t\t\t\t\t\t--><rs-layer\n\t\t\t\t\t\t\t\tid=\"slider-3-slide-12-layer-1\" \n\t\t\t\t\t\t\t\tdata-type=\"text\"\n\t\t\t\t\t\t\t\tdata-rsp_ch=\"on\"\n\t\t\t\t\t\t\t\tdata-xy=\"xo:111px,111px,111px,9px;yo:300px,300px,300px,88px;\"\n\t\t\t\t\t\t\t\tdata-text=\"w:normal;s:27,27,27,16;l:31,31,31,22;\"\n\t\t\t\t\t\t\t\tdata-dim=\"w:414,414,414,139px;\"\n\t\t\t\t\t\t\t\tdata-frame_1=\"e:power2.inOut;st:500;sR:500;\"\n\t\t\t\t\t\t\t\tdata-frame_999=\"o:0;e:nothing;st:w;sR:2200;\"\n\t\t\t\t\t\t\t\tstyle=\"z-index:8;font-family:'Open Sans';\"\n\t\t\t\t\t\t\t>W Balsam Medica spotkasz najlepszych specjalist\u00f3w, \nkt\u00f3rzy wsp\u00f3lnie wypracuj\u0105 dla Ciebie najlepsze opcje terapeutyczne. \n<br \/><br \/>\nMo\u017cesz nam zaufa\u0107. \n\t\t\t\t\t\t\t<\/rs-layer><!--\n\n\t\t\t\t\t\t\t--><h1\n\t\t\t\t\t\t\t\tid=\"slider-3-slide-12-layer-2\" \n\t\t\t\t\t\t\t\tclass=\"rs-layer\"\n\t\t\t\t\t\t\t\tdata-type=\"text\"\n\t\t\t\t\t\t\t\tdata-rsp_ch=\"on\"\n\t\t\t\t\t\t\t\tdata-xy=\"xo:115px,115px,115px,9px;yo:222px,222px,222px,88px;\"\n\t\t\t\t\t\t\t\tdata-text=\"w:nowrap,nowrap,nowrap,normal;s:51,51,51,16;l:59,59,59,22;\"\n\t\t\t\t\t\t\t\tdata-dim=\"w:413,413,413,139px;h:84,84,84,auto;\"\n\t\t\t\t\t\t\t\tdata-frame_1=\"e:power2.inOut;st:500;sR:500;\"\n\t\t\t\t\t\t\t\tdata-frame_999=\"o:0;e:nothing;st:w;sR:2200;\"\n\t\t\t\t\t\t\t\tstyle=\"z-index:7;font-family:'Open Sans';\"\n\t\t\t\t\t\t\t>O naszej klinice \n\t\t\t\t\t\t\t<\/h1><!--\n-->\t\t\t\t\t\t<\/rs-slide>\n\t\t\t\t\t<\/rs-slides>\n\t\t\t\t\t<rs-static-layers><!--\n\t\t\t\t\t--><\/rs-static-layers>\n\t\t\t\t<\/rs-module>\n\t\t\t\t<script>\n\t\t\t\t\tsetREVStartSize({c: 'rev_slider_3_1',rl:[1240,1240,1240,480],el:[720,720,720,260],gw:[1920,1920,1920,480],gh:[720,720,720,260],type:'standard',justify:'',layout:'fullwidth',mh:\"0\"});if (window.RS_MODULES!==undefined && window.RS_MODULES.modules!==undefined && window.RS_MODULES.modules[\"revslider31\"]!==undefined) {window.RS_MODULES.modules[\"revslider31\"].once = false;window.revapi3 = undefined;if (window.RS_MODULES.checkMinimal!==undefined) window.RS_MODULES.checkMinimal()}\n\t\t\t\t<\/script>\n\t\t\t<\/rs-module-wrap>\n\t\t\t<!-- END REVOLUTION SLIDER -->\n<\/div>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"cmsmasters_row_\" class=\"cmsmasters_row cmsmasters_color_scheme_default cmsmasters_row_top_default cmsmasters_row_bot_default cmsmasters_row_boxed\">\n<div class=\"cmsmasters_row_outer_parent\">\n<div class=\"cmsmasters_row_outer\">\n<div class=\"cmsmasters_row_inner\">\n<div class=\"cmsmasters_row_margin\">\n<div id=\"cmsmasters_column_\" class=\"cmsmasters_column one_first\">\n<div class=\"cmsmasters_column_inner\"><div class=\"cmsmasters_text\">\n<h1>Formularz zg\u0142oszeniowy<\/h1>\n<\/div>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div id=\"cmsmasters_row_k9nnu21kh\" class=\"cmsmasters_row cmsmasters_color_scheme_default cmsmasters_row_top_default cmsmasters_row_bot_default cmsmasters_row_boxed\">\n<div class=\"cmsmasters_row_outer_parent\">\n<div class=\"cmsmasters_row_outer\">\n<div class=\"cmsmasters_row_inner\">\n<div class=\"cmsmasters_row_margin\">\n<div id=\"cmsmasters_column_59z6fids2\" class=\"cmsmasters_column one_first\">\n<div class=\"cmsmasters_column_inner\"><div class=\"cmsmasters_contact_form\"><style id=\"wpforms-css-vars-15564\">\n\t\t\t\t#wpforms-15564 {\n\t\t\t\t--wpforms-field-border-color: rgba(0, 0, 0, 0.25);\n--wpforms-field-border-color-spare: rgba(0, 0, 0, 0.25);\n--wpforms-field-text-color: rgba(0, 0, 0, 0.7);\n--wpforms-label-color: rgba(0, 0, 0, 0.85);\n--wpforms-label-sublabel-color: rgba(0, 0, 0, 0.55);\n--wpforms-button-background-color: #0c141a;\n--wpforms-container-padding: 0px;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-radius: 3px;\n--wpforms-background-color: rgba(0, 0, 0, 0);\n--wpforms-field-size-input-height: 31px;\n--wpforms-field-size-input-spacing: 10px;\n--wpforms-field-size-font-size: 14px;\n--wpforms-field-size-line-height: 17px;\n--wpforms-field-size-padding-h: 9px;\n--wpforms-field-size-checkbox-size: 14px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 0.75;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-15564\"><form id=\"wpforms-form-15564\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"15564\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/pl\/wp-json\/wp\/v2\/pages\/15588\" data-token=\"288965736bfd6b88433f433bac128030\" data-token-time=\"1779813283\"><noscript class=\"wpforms-error-noscript\">Aby wype\u0142ni\u0107 ten formularz, w\u0142\u0105cz obs\u0142ug\u0119 JavaScript w przegl\u0105darce.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Aby wype\u0142ni\u0107 ten formularz, w\u0142\u0105cz obs\u0142ug\u0119 JavaScript w przegl\u0105darce.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-15564-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-15564-field_2\">Imi\u0119 i nazwisko <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15564-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" aria-errormessage=\"wpforms-15564-field_2-error\" required><\/div><div id=\"wpforms-15564-field_3-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-15564-field_3\">Numer telefonu <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-15564-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" step=\"any\" aria-errormessage=\"wpforms-15564-field_3-error\" aria-describedby=\"wpforms-15564-field_3-description\" required><div id=\"wpforms-15564-field_3-description\" class=\"wpforms-field-description\">+48<\/div><\/div><div id=\"wpforms-15564-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-15564-field_1\">Adres e-mail <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-15564-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-15564-field_1-error\" required><\/div><div id=\"wpforms-15564-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-15564-field_4\">Choroba<\/label><input type=\"text\" id=\"wpforms-15564-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-15564-field_4-error\" ><\/div><div id=\"wpforms-15564-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-15564-field_5\">Kod pocztowy <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-15564-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-15564-field_5-error\" required><\/div><div id=\"wpforms-15564-field_6-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"6\"><fieldset><legend class=\"wpforms-field-label\">P\u0142e\u0107 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15564-field_6\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-15564-field_6_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][6][]\" value=\"Kobieta\" aria-errormessage=\"wpforms-15564-field_6_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15564-field_6_1\">Kobieta<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-15564-field_6_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][6][]\" value=\"M\u0119\u017cczyzna\" aria-errormessage=\"wpforms-15564-field_6_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15564-field_6_2\">M\u0119\u017cczyzna<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-15564-field_6_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][6][]\" value=\"Inne\/wole nie odpowiada\u0107\" aria-errormessage=\"wpforms-15564-field_6_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15564-field_6_3\">Inne\/wole nie odpowiada\u0107<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-15564-field_9-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">Czy bierze Pan\/Pani udzia\u0142 w innych badaniach klinicznych? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15564-field_9\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-15564-field_9_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"Tak\" aria-errormessage=\"wpforms-15564-field_9_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15564-field_9_1\">Tak<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-15564-field_9_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][9][]\" value=\"Nie\" aria-errormessage=\"wpforms-15564-field_9_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15564-field_9_2\">Nie<\/label><\/li><\/ul><\/fieldset><\/div>\t\t<div id=\"wpforms-15564-field_7-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"7\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-15564-field_7\" >i w udzia\u0142<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-15564-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-15564-field_8-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\"> <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-15564-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-15564-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Wyra\u017cam zgod\u0119\" aria-errormessage=\"wpforms-15564-field_8_1-error\" aria-describedby=\"wpforms-15564-field_8-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-15564-field_8_1\">Wyra\u017cam zgod\u0119<\/label><\/li><\/ul><div id=\"wpforms-15564-field_8-description\" class=\"wpforms-field-description\">Administratorem danych osobowych zawartych w formularzu kontaktowym jest BalsamMedica Sp. z o.o. z siedzib\u0105 w Warszawie. Dane b\u0119d\u0105 przetwarzane w celu identyfikacji nadawcy oraz obs\u0142ugi zapytania na zasadach okre\u015blonych w Polityce prywatno\u015bci. Podanie danych jest dobrowolne, ale konieczne dla przes\u0142ania zapytania.<\/div><\/fieldset><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-15564-field_7-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-15564-field_7-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-15564-field_7-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"15564\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/pages\/15588\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-15564\" class=\"wpforms-submit\" data-alt-text=\"Wysy\u0142anie...\" data-submit-text=\"Prze\u015blij\" aria-live=\"assertive\" value=\"wpforms-submit\">Prze\u015blij<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/balsam-medica.pl\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Wczytywanie\"><\/div><\/form><\/div>  <!-- .wpforms-container --><\/div>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-15588","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/pages\/15588","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/comments?post=15588"}],"version-history":[{"count":5,"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/pages\/15588\/revisions"}],"predecessor-version":[{"id":15594,"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/pages\/15588\/revisions\/15594"}],"wp:attachment":[{"href":"https:\/\/balsam-medica.pl\/pl\/wp-json\/wp\/v2\/media?parent=15588"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}