{"id":498,"date":"2023-03-29T10:48:33","date_gmt":"2023-03-29T08:48:33","guid":{"rendered":"https:\/\/websilver.pl\/?page_id=498"},"modified":"2023-03-29T11:00:25","modified_gmt":"2023-03-29T09:00:25","slug":"formularz-mozliwosc-przyjecia-pensjonariusza-2-2-2","status":"publish","type":"page","link":"https:\/\/websilver.pl\/index.php\/formularz-mozliwosc-przyjecia-pensjonariusza-2-2-2\/","title":{"rendered":"Formularz WS02 &#8211; za\u015bwiadczenie lekarskie"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"498\" class=\"elementor elementor-498\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1df6664 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"1df6664\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-e9a54f9\" data-id=\"e9a54f9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-48a6e9b elementor-widget elementor-widget-shortcode\" data-id=\"48a6e9b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f445-o1\" lang=\"pl-PL\" dir=\"ltr\" data-wpcf7-id=\"445\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/498#wpcf7-f445-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formularz kontaktowy\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"445\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"pl_PL\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f445-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p><b>Formularz WS02 - <\/b> za\u015bwiadczenie lekarskie\n<\/p>\n<p><mark>Niniejszy dokument jest dokumentem informacyjnym o stanie zdrowia pensjonariusza.<\/mark>\n<\/p>\n<p>1. Imi\u0119 i nazwisko pensjonariusza <i>(pole wymagane)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n<\/p>\n<p>2. Wiek <i>(pole wymagane)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wiek\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"wiek\" \/><\/span>\n<\/p>\n<p>3. Czy osoba jest przewlekle chora i stan jej zdrowia nie wymaga leczenia szpitalnego?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"przewlekle_chory\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"przewlekle_chory[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"przewlekle_chory[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>4. Czy osoba ze wzgl\u0119du na stan zdrowia wymaga STA\u0141EJ ca\u0142odobowej opieki?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"opieka_stala\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"opieka_stala[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"opieka_stala[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p> Czy osoba ze wzgl\u0119du na stan zdrowia wymaga OKRESOWEJ ca\u0142odobowej opieki?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"opieka_okresowa\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"opieka_okresowa[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"opieka_okresowa[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>5. Prosz\u0119 poda\u0107 zakres \u015bwiadcze\u0144 zdrowotnych niezb\u0119dnych do zapewnienia przez dom opieki\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"swiadczenia\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"swiadczenia[]\" value=\"piel\u0119gnacja chorych\" \/><span class=\"wpcf7-list-item-label\">piel\u0119gnacja chorych<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"swiadczenia[]\" value=\"piel\u0119gnacja i opieka nad niepe\u0142nosprawnymi\" \/><span class=\"wpcf7-list-item-label\">piel\u0119gnacja i opieka nad niepe\u0142nosprawnymi<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"swiadczenia[]\" value=\"leczenie, badania i porady lekarskie\" \/><span class=\"wpcf7-list-item-label\">leczenie, badania i porady lekarskie<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"swiadczenia[]\" value=\"rehabilitacja lecznicza\" \/><span class=\"wpcf7-list-item-label\">rehabilitacja lecznicza<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"swiadczenia[]\" value=\"badania i terapia psychologiczna\" \/><span class=\"wpcf7-list-item-label\">badania i terapia psychologiczna<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"swiadczenia[]\" value=\"dzia\u0142ania zapobiegawcze\" \/><span class=\"wpcf7-list-item-label\">dzia\u0142ania zapobiegawcze<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>6. Czy istniej\u0105 przeciwwskazania do umieszczenia w domu pomocy spo\u0142ecznej?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"przeciwwskazania\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"przeciwwskazania[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"przeciwwskazania[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p> Czy jest zalecana konsultacja lekarza psychiatry?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"psychiatra\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"psychiatra[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"psychiatra[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p> Czy jest zalecana konsultacja psychologa?\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"psycholog\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"psycholog[]\" value=\"TAK\" \/><span class=\"wpcf7-list-item-label\">TAK<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"psycholog[]\" value=\"NIE\" \/><span class=\"wpcf7-list-item-label\">NIE<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>7. Zalecany profil domu opieki\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"profil\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"profil[]\" value=\"dla os\u00f3b w podesz\u0142ym wieku\" \/><span class=\"wpcf7-list-item-label\">dla os\u00f3b w podesz\u0142ym wieku<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"profil[]\" value=\"dla os\u00f3b przewlekle somatycznie chorych\" \/><span class=\"wpcf7-list-item-label\">dla os\u00f3b przewlekle somatycznie chorych<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"profil[]\" value=\"dla os\u00f3b przewlekle psychicznie chorych\" \/><span class=\"wpcf7-list-item-label\">dla os\u00f3b przewlekle psychicznie chorych<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"profil[]\" value=\"dla doros\u0142ych niepe\u0142nosprawnych intelektualnie\" \/><span class=\"wpcf7-list-item-label\">dla doros\u0142ych niepe\u0142nosprawnych intelektualnie<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"profil[]\" value=\"dla os\u00f3b niepe\u0142nosprawnych fizycznie\" \/><span class=\"wpcf7-list-item-label\">dla os\u00f3b niepe\u0142nosprawnych fizycznie<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>8. Wype\u0142niaj\u0105c niniejszy formularz przekazuj\u0119 swoje dane osobowe, kt\u00f3re wykorzystane zostan\u0105<br \/>\nwy\u0142\u0105cznie na udzielenie odpowiedzi oraz akceptuj\u0119 polityk\u0119 prywatno\u015bci serwisu webSilver.pl.<br \/>\nPodanie danych jest dobrowolne. Podstaw\u0105 przetwarzania danych jest zgoda, o kt\u00f3rej mowa w<br \/>\nart. 6 ust. 1 lit. a Rozporz\u0105dzenia Parlamentu Europejskiego i Rady (UE) 2016\/679 z dnia 27<br \/>\nkwietnia 2016 r. (w skr\u00f3cie RODO).\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rodo\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"rodo\" value=\"1\" aria-invalid=\"false\" \/><\/span><\/span><\/span><i>(pole wymagane)<\/i>\n<\/p>\n<p> Twoja wiadomo\u015bci <i>(opcjonalne)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-message\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-message\"><\/textarea><\/span>\n<\/p>\n<p>9. Tw\u00f3j adres e-mail <i>(pole wymagane)<\/i>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n<\/p>\n<p><mark>Wszelkie uwagi i korespondencj\u0119 prosimy o wysy\u0142anie na adres e-mail podany w sekcji Kontakty w serwisie www.websilver.pl<\/mark>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Wy\u015blij\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"118\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-498","page","type-page","status-publish","hentry"],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages\/498","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/comments?post=498"}],"version-history":[{"count":6,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages\/498\/revisions"}],"predecessor-version":[{"id":504,"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/pages\/498\/revisions\/504"}],"wp:attachment":[{"href":"https:\/\/websilver.pl\/index.php\/wp-json\/wp\/v2\/media?parent=498"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}