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date = '2024-02-21T13:22:03Z'
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draft = false
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title = 'Zusatzmodule Freiberufliche'
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translationKey = "zusatzmodule-freiberufliche"
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bestellformular = true
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{{% section %}} {{% aligncenter %}}
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2024-04-18 11:16:24 +02:00
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#### Bestellformular
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## VeruA App
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### Zusatzmodule für Freiberufliche
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<br>
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---
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<br>
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{{% /aligncenter %}}
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2024-04-26 23:12:43 +02:00
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<form action="/php/ajaxmail.php" method="POST" id="bestellformular">
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<input type="hidden" name="formularart" value="Bestellung Zusatzmodule VeruA App - Freiberufliche Pflegefachperson">
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<div>
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<label class="hidden" for="gender">Geschlecht</label>
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<select id="gender" name="gender" required >
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<option value="Frau">Frau</option>
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<option value="Herr">Herr</option>
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<option value="Frau Dr.">Frau Dr.</option>
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<option value="Herr Dr.">Herr Dr.</option>
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<option value="">Keine Angabe</option>
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</select>
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</div>
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<div>
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<label for="vorname">Vorname</label>
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<input type="text" id="vorname" name="vorname" required >
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</div>
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<div>
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<label for="name">Nachname</label>
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<input type="text" id="name" name="name" required >
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</div>
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<div>
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<input type="hidden" id="sprache" name="sprache" value="DE">
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</div>
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<div>
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<input type="text" id="hobbies" name="hobbies" autocomplete="off">
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</div>
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<div>
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<label for="strasse">Strasse und Hausnummer</label>
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<input type="text" id="strasse" name="strasse" required >
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</div>
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<div>
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<input type="text" id="age" name="age" autocomplete="off">
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</div>
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<div>
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<label for="plz_ort">PLZ Ort</label>
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<input type="text" id="plz_ort" name="plz_ort" required >
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</div>
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<div>
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<label for="telefon">Telefon</label>
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<input type="text" id="telefon" name="telefon" required >
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</div>
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<div>
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<label for="email">Email</label>
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<input type="email" id="email" name="email" required >
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</div>
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<div>
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<input type="verify_email" id="verify_email" name="verify_email" autocomplete="off">
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</div>
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<div><br><br>
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<h5>Welche Erweiterungen möchten Sie hinzubuchen?</h5><br>
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<div id="checkbox-group">
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<input type="checkbox" id="zusatzmodul-pop2" name="zusatzmodul-pop2" value="Zusatzmodul POP2: Bereitstellung, einmalig 438.00 CHF; Jährliche Lizenzkosten 42.00 CHF">
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<label for="zusatzmodul-pop2">Zusatzmodul POP2: Bereitstellung, einmalig 438.00 CHF; Jährliche Lizenzkosten 42.00 CHF</label>
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<br>
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<input type="checkbox" id="zusatzmodul-materialverwaltung" name="zusatzmodul-materialverwaltung" value="Zusatzmodul Material: Bereitstellung, einmalig 342.00 CHF; Jährliche Lizenzkosten 138.00 CHF">
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<label for="zusatzmodul-materialverwaltung">Zusatzmodul Material: Bereitstellung, einmalig 342.00 CHF; Jährliche Lizenzkosten 138.00 CHF</label>
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<br>
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<input type="checkbox" id="zusatzmodul-qr-code" name="zusatzmodul-qr-code" value="Zusatzmodul QR-Code: Bereitstellung, einmalig pro Instanz 50.00 CHF; Jährliche Lizenzkosten 36.00 CHF">
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<label for="zusatzmodul-qr-code">Zusatzmodul QR-Code: Bereitstellung, einmalig pro Instanz 50.00 CHF; Jährliche Lizenzkosten 36.00 CHF</label>
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<br>
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<input type="checkbox" id="zusatzmodul-perigon" name="zusatzmodul-perigon" value="Zusatzmodul Perigon: Bereitstellung, einmalig 50.00 CHF">
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<label for="zusatzmodul-perigon">Zusatzmodul Perigon: Bereitstellung, einmalig 50.00 CHF</label>
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</div>
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<div><br><br>
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<center class="w-full">
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{{< captcha >}}
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<button id="bestellformular-btn" type="submit" class="submitbutton text-white mx-auto submit-after-valid-captcha" >Kostenpflichtig bestellen</button>
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<p><div id="notification" class="bg-blue-500 text-white rounded invisible opacity-0 hidden">Notification</div></p>
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</center>
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</form>
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{{% /section %}}
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