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class="adverse__form__navigation__button js-adverse-form-navigation-button" aria-label="4"> <span class="adverse__form__navigation__button__text js-adverse-form-navigation-text">4</span> <i class="adverse__form__navigation__button__icon icon-check js-adverse-form-navigation-icon" aria-hidden="true"></i> </button> </div> <div class="adverse__forms"> <div class="adverse__form form js-adverse-form js-adverse-form-step1"> <div class="form__group"> <h2 class="form__group__title">Hastaya Ait Bilgiler</h2> </div> <div class="form__group group--half group--left"> <label for="hastaAdiSoyadiBasHarfleri" class="form__label">Hastan谋n Ad谋 ve Soyad谋n谋n Ba艧 Harfleri</label> <input id="hastaAdiSoyadiBasHarfleri" name="hastaAdiSoyadiBasHarfleri" type="text" class="form__input" placeholder="Hastan谋n Ad谋 ve Soyad谋n谋n Ba艧 Harfleri" spellcheck="false" autocomplete="off" minlength="2" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="hastaDogumTarihi" class="form__label">Do臒um Tarihi</label> <input id="hastaDogumTarihi" name="hastaDogumTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--left"> <label for="hastaYasi" class="form__label">Ya艧*</label> <input id="hastaYasi" name="hastaYasi" type="tel" class="form__input js-only-number" placeholder="Ya艧" spellcheck="false" autocomplete="off" minlength="1" maxlength="3" required="required" /> </div> <div class="form__group group--select group--half group--right"> <label for="hastaCinsiyeti" class="form__label">Cinsiyet*</label> <select id="hastaCinsiyeti" name="hastaCinsiyeti" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Cinsiyet" data-search="false" required="required"> <option hidden value=""></option> <option value="Kad谋n">Kad谋n</option> <option value="Erkek">Erkek</option> </select> </div> <div class="form__group group--half group--left"> <label for="hastaBoyu" class="form__label">Boy (cm)</label> <input id="hastaBoyu" name="hastaBoyu" type="tel" class="form__input js-only-number" placeholder="Boy (cm)" spellcheck="false" autocomplete="off" minlength="1" maxlength="3" /> </div> <div class="form__group group--half group--right"> <label for="hastaAgirligi" class="form__label">A臒谋rl谋k (kg)</label> <input id="hastaAgirligi" name="hastaAgirligi" type="tel" class="form__input js-only-number" placeholder="A臒谋rl谋k (kg)" spellcheck="false" autocomplete="off" minlength="1" maxlength="4" /> </div> <div class="form__group group--info"> <p class="form__info"> <i class="form__info__icon icon-info-circle"></i> <span class="form__info__text">Doldurulmas谋 zorunlu alanlar <b>*</b> ile belirtilmi艧tir.</span> </p> </div> <div class="form__group group--divider"></div> <div class="form__group group--half group--left group--zero"></div> <div class="form__group group--submit group--half group--right"> <button type="button" class="button button--secondary button--full js-adverse-button-validate js-adverse-button-step1"> <span>Devam Et</span> </button> </div> </div> <div class="adverse__form form js-adverse-form js-adverse-form-step2 state--passive"> <div class="form__group"> <h2 class="form__group__title">Yan Etkiler</h2> </div> <div class="form__group"> <label for="yanEtkiTanimi" class="form__label">Yan Etki/Etkileri Tan谋mlay谋n谋z*</label> <textarea id="yanEtkiTanimi" name="yanEtkiTanimi" class="form__textarea scrollbar--secondary" placeholder="Yan Etki/Etkileri Tan谋mlay谋n谋z" spellcheck="false" rows="8" autocomplete="off" minlength="10" maxlength="1000" required="required"></textarea> </div> <div class="form__group group--half group--left"> <label for="yanEtkiBaslangicTarihi" class="form__label">Ba艧lang谋莽 Tarihi</label> <input id="yanEtkiBaslangicTarihi" name="yanEtkiBaslangicTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="yanEtkiBitisTarihi" class="form__label">Biti艧 Tarihi</label> <input id="yanEtkiBitisTarihi" name="yanEtkiBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="yanEtkiSonuc" class="form__label">Sonu莽</label> <select id="yanEtkiSonuc" name="yanEtkiSonuc" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Sonu莽" data-search="false"> <option hidden value=""></option> <option value="陌yile艧ti/D眉zeldi">陌yile艧ti/D眉zeldi</option> <option value="陌yile艧iyor/D眉zeliyor">陌yile艧iyor/D眉zeliyor</option> <option value="Sekel B谋rakarak 陌yile艧ti/D眉zeldi">Sekel B谋rakarak 陌yile艧ti/D眉zeldi</option> <option value="Devam Ediyor">Devam Ediyor</option> <option value="脰l眉mle Sonu莽land谋">脰l眉mle Sonu莽land谋</option> <option value="Bilinmiyor">Bilinmiyor</option> <option value="Di臒er">Di臒er</option> </select> </div> <div class="form__group group--divider"></div> <div class="form__group group--select"> <label for="ciddiyetKriteri" class="form__label">Ciddiyet Kriteri*</label> <select id="ciddiyetKriteri" name="ciddiyetKriteri" class="form__select js-select2 js-adverse-form-critical" data-theme-class="select--primary" data-placeholder="Ciddiyet Kriteri" data-search="false" required="required"> <option hidden value=""></option> <option value="Ciddi">Ciddi</option> <option value="Ciddi Olmayan">Ciddi Olmayan</option> </select> </div> <div class="form__group group--background state--passive js-adverse-form-critical-group"> <div class="form__group group--checkbox"> <input data-clone="hastaOlduMu" name="hastaOlduMu" type="text" class="form__checkbox--hidden" value="false" /> <input id="hastaOlduMu" type="checkbox" class="form__checkbox js-checkbox-clone js-adverse-form-death" value="true" /> <label for="hastaOlduMu" class="form__checkbox__label form__checkbox__info">脰l眉m</label> </div> <div class="form__group group--row group--zero js-adverse-form-death-group state--passive"> <div class="form__group group--triple group--left"> <label for="hastaOlumTarihi" class="form__label">脰l眉m Tarihi</label> <input id="hastaOlumTarihi" name="hastaOlumTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--triple group--center"> <label for="hastaOlumNedeni" class="form__label">脰l眉m Nedeni</label> <input id="hastaOlumNedeni" name="hastaOlumNedeni" type="text" class="form__input" placeholder="脰l眉m Nedeni" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--select group--triple group--right"> <label for="otopsiYapildiMi" class="form__label">Otopsi Yap谋ld谋 m谋?</label> <select id="otopsiYapildiMi" name="otopsiYapildiMi" class="form__select js-select2 js-adverse-form-autopsy" data-theme-class="select--primary" data-placeholder="Otopsi Yap谋ld谋 m谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> </select> </div> <div class="form__group group--file state--passive js-adverse-form-autopsy-group"> <label for="otopsiBelgesiPDF" class="form__label js-adverse-form-autopsy-file-label" data-title="Belge Ekle" data-error="Belge, en fazla 3MB boyutunda ve PDF format谋nda olmal谋d谋r.">Belge Ekle</label> <button type="button" aria-label="Temizle" class="js-adverse-form-autopsy-file-clear"> <i class="icon-plus"></i> </button> <input id="otopsiBelgesiPDF" type="file" accept="application/pdf" class="form__file js-adverse-form-autopsy-file" data-endpoint="/api/adverseeffectsreportform/fileupload" /> </div> </div> <div class="form__group group--checkbox"> <input data-clone="hastaneyeYatirildiMi" name="hastaneyeYatirildiMi" type="text" class="form__checkbox--hidden" value="false" /> <input id="hastaneyeYatirildiMi" type="checkbox" class="form__checkbox js-checkbox-clone" value="true" /> <label for="hastaneyeYatirildiMi" class="form__checkbox__label form__checkbox__info">Hastaneye Yat谋艧a Sebep Olma ve/veya Yat谋艧 S眉resini Uzatma</label> </div> <div class="form__group group--checkbox"> <input data-clone="kaliciHasarVeyaSakatlikVerdiMi" name="kaliciHasarVeyaSakatlikVerdiMi" type="text" class="form__checkbox--hidden" value="false" /> <input id="kaliciHasarVeyaSakatlikVerdiMi" type="checkbox" class="form__checkbox js-checkbox-clone" value="true" /> <label for="kaliciHasarVeyaSakatlikVerdiMi" class="form__checkbox__label form__checkbox__info">Kal谋c谋 veya Belirgin Sakatl谋臒a veya 陌艧 g枚remezli臒e Neden Olma</label> </div> <div class="form__group group--checkbox"> <input data-clone="anomaliVeyaDogumKusuruOlduMu" name="anomaliVeyaDogumKusuruOlduMu" type="text" class="form__checkbox--hidden" value="false" /> <input id="anomaliVeyaDogumKusuruOlduMu" type="checkbox" class="form__checkbox js-checkbox-clone" value="true" /> <label for="anomaliVeyaDogumKusuruOlduMu" class="form__checkbox__label form__checkbox__info">Konjenital Anomali ve/veya Do臒um Kusuru</label> </div> <div class="form__group group--checkbox"> <input data-clone="tibbiOlarakOnemliMi" name="hastaneyeYatibbiOlarakOnemliMitirildiMi" type="text" class="form__checkbox--hidden" value="false" /> <input id="tibbiOlarakOnemliMi" type="checkbox" class="form__checkbox js-checkbox-clone" value="true" /> <label for="tibbiOlarakOnemliMi" class="form__checkbox__label form__checkbox__info">T谋bbi Olarak 脰nemli</label> </div> </div> <div class="form__group group--half group--left"> <label for="laboratuvarBulgulari" class="form__label">Laboratuvar Bulgular谋</label> <textarea id="laboratuvarBulgulari" name="laboratuvarBulgulari" class="form__textarea scrollbar--secondary" placeholder="Tarihleriyle birlikte (G眉n/Ay/Y谋l)" spellcheck="false" rows="8" autocomplete="off" maxlength="1000" minlength="10"></textarea> </div> <div class="form__group group--half group--right"> <label for="tibbiOykuVeyaEsZamanliHastaliklar" class="form__label">陌lgili T谋bbi 脰yk眉 / E艧 Zamanl谋 Hastal谋klar</label> <textarea id="tibbiOykuVeyaEsZamanliHastaliklar" name="tibbiOykuVeyaEsZamanliHastaliklar" class="form__textarea scrollbar--secondary" placeholder="脰rne臒in: Allerji, gebelik, sigara ve alkol kullan谋m谋, hepatik/renal yetmezlik, diyabet, hipertansiyon...v.b) Konjenital anomaliler i莽in gebelikte annenin ald谋臒谋 t眉m ila莽lar ve maruz kald谋臒谋 hastal谋klar ile birlikte son mensturasyon tarihini de belirtiniz. (G眉n/Ay/Y谋l)" spellcheck="false" rows="8" autocomplete="off" maxlength="1000" minlength="10"></textarea> </div> <div class="form__group group--info"> <p class="form__info"> <i class="form__info__icon icon-info-circle"></i> <span class="form__info__text">Doldurulmas谋 zorunlu alanlar <b>*</b> ile belirtilmi艧tir.</span> </p> </div> <div class="form__group group--divider"></div> <div class="form__group group--submit group--half group--left order-2 order-lg-1"> <button type="button" class="button button--primary button--full js-adverse-button-gotoprev"> <span>Geri D枚n</span> </button> </div> <div class="form__group group--submit group--half group--right order-1 order-lg-2"> <button type="button" class="button button--secondary button--full js-adverse-button-validate js-adverse-button-step2"> <span>Devam Et</span> </button> </div> </div> <div class="adverse__form form js-adverse-form js-adverse-form-step3 state--passive"> <div class="form__group"> <h2 class="form__group__title">Kullan谋lan T谋bbi 脺r眉nler</h2> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions " data-prefix="suphe1"> <div class="form__group group--half group--left"> <label for="suphe1__s1_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe1__s1_supheEdilenIlacAdi" name="suphe1__s1_supheEdilenIlacAdi" data-propertyname="s1_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe1__s1_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe1__s1_verilisYolu" name="suphe1__s1_verilisYolu" data-propertyname="s1_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe1__s1_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe1__s1_endikasyonu" name="suphe1__s1_endikasyonu" data-propertyname="s1_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe1__s1_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe1__s1_gunlukDozu" name="suphe1__s1_gunlukDozu" data-propertyname="s1_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe1__s1_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe1__s1_ilacaBaslamaTarihi" name="suphe1__s1_ilacaBaslamaTarihi" data-propertyname="s1_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe1__s1_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe1__s1_ilacinBitisTarihi" name="suphe1__s1_ilacinBitisTarihi" data-propertyname="s1_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe1__s1_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe1__s1_ilacaAraVerildiMi" name="suphe1__s1_ilacaAraVerildiMi" data-propertyname="s1_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe1__s1_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe1__s1_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe1__s1_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s1_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe1__s1_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe1__s1_ilacYenidenVerildiMi" name="suphe1__s1_ilacYenidenVerildiMi" data-propertyname="s1_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe1__s1_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe1__s1_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe1__s1_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s1_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe2"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe2__s2_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe2__s2_supheEdilenIlacAdi" name="suphe2__s2_supheEdilenIlacAdi" data-propertyname="s2_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe2__s2_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe2__s2_verilisYolu" name="suphe2__s2_verilisYolu" data-propertyname="s2_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe2__s2_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe2__s2_endikasyonu" name="suphe2__s2_endikasyonu" data-propertyname="s2_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe2__s2_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe2__s2_gunlukDozu" name="suphe2__s2_gunlukDozu" data-propertyname="s2_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe2__s2_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe2__s2_ilacaBaslamaTarihi" name="suphe2__s2_ilacaBaslamaTarihi" data-propertyname="s2_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe2__s2_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe2__s2_ilacinBitisTarihi" name="suphe2__s2_ilacinBitisTarihi" data-propertyname="s2_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe2__s2_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe2__s2_ilacaAraVerildiMi" name="suphe2__s2_ilacaAraVerildiMi" data-propertyname="s2_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe2__s2_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe2__s2_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe2__s2_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s2_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe2__s2_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe2__s2_ilacYenidenVerildiMi" name="suphe2__s2_ilacYenidenVerildiMi" data-propertyname="s2_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe2__s2_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe2__s2_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe2__s2_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s2_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe3"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe3__s3_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe3__s3_supheEdilenIlacAdi" name="suphe3__s3_supheEdilenIlacAdi" data-propertyname="s3_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe3__s3_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe3__s3_verilisYolu" name="suphe3__s3_verilisYolu" data-propertyname="s3_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe3__s3_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe3__s3_endikasyonu" name="suphe3__s3_endikasyonu" data-propertyname="s3_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe3__s3_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe3__s3_gunlukDozu" name="suphe3__s3_gunlukDozu" data-propertyname="s3_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe3__s3_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe3__s3_ilacaBaslamaTarihi" name="suphe3__s3_ilacaBaslamaTarihi" data-propertyname="s3_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe3__s3_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe3__s3_ilacinBitisTarihi" name="suphe3__s3_ilacinBitisTarihi" data-propertyname="s3_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe3__s3_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe3__s3_ilacaAraVerildiMi" name="suphe3__s3_ilacaAraVerildiMi" data-propertyname="s3_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe3__s3_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe3__s3_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe3__s3_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s3_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe3__s3_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe3__s3_ilacYenidenVerildiMi" name="suphe3__s3_ilacYenidenVerildiMi" data-propertyname="s3_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe3__s3_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe3__s3_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe3__s3_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s3_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe4"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe4__s4_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe4__s4_supheEdilenIlacAdi" name="suphe4__s4_supheEdilenIlacAdi" data-propertyname="s4_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe4__s4_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe4__s4_verilisYolu" name="suphe4__s4_verilisYolu" data-propertyname="s4_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe4__s4_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe4__s4_endikasyonu" name="suphe4__s4_endikasyonu" data-propertyname="s4_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe4__s4_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe4__s4_gunlukDozu" name="suphe4__s4_gunlukDozu" data-propertyname="s4_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe4__s4_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe4__s4_ilacaBaslamaTarihi" name="suphe4__s4_ilacaBaslamaTarihi" data-propertyname="s4_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe4__s4_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe4__s4_ilacinBitisTarihi" name="suphe4__s4_ilacinBitisTarihi" data-propertyname="s4_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe4__s4_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe4__s4_ilacaAraVerildiMi" name="suphe4__s4_ilacaAraVerildiMi" data-propertyname="s4_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe4__s4_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe4__s4_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe4__s4_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s4_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe4__s4_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe4__s4_ilacYenidenVerildiMi" name="suphe4__s4_ilacYenidenVerildiMi" data-propertyname="s4_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe4__s4_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe4__s4_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe4__s4_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s4_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe5"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe5__s5_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe5__s5_supheEdilenIlacAdi" name="suphe5__s5_supheEdilenIlacAdi" data-propertyname="s5_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe5__s5_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe5__s5_verilisYolu" name="suphe5__s5_verilisYolu" data-propertyname="s5_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe5__s5_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe5__s5_endikasyonu" name="suphe5__s5_endikasyonu" data-propertyname="s5_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe5__s5_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe5__s5_gunlukDozu" name="suphe5__s5_gunlukDozu" data-propertyname="s5_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe5__s5_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe5__s5_ilacaBaslamaTarihi" name="suphe5__s5_ilacaBaslamaTarihi" data-propertyname="s5_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe5__s5_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe5__s5_ilacinBitisTarihi" name="suphe5__s5_ilacinBitisTarihi" data-propertyname="s5_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe5__s5_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe5__s5_ilacaAraVerildiMi" name="suphe5__s5_ilacaAraVerildiMi" data-propertyname="s5_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe5__s5_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe5__s5_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe5__s5_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s5_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe5__s5_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe5__s5_ilacYenidenVerildiMi" name="suphe5__s5_ilacYenidenVerildiMi" data-propertyname="s5_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe5__s5_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe5__s5_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe5__s5_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s5_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe6"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe6__s6_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe6__s6_supheEdilenIlacAdi" name="suphe6__s6_supheEdilenIlacAdi" data-propertyname="s6_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe6__s6_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe6__s6_verilisYolu" name="suphe6__s6_verilisYolu" data-propertyname="s6_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe6__s6_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe6__s6_endikasyonu" name="suphe6__s6_endikasyonu" data-propertyname="s6_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe6__s6_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe6__s6_gunlukDozu" name="suphe6__s6_gunlukDozu" data-propertyname="s6_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe6__s6_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe6__s6_ilacaBaslamaTarihi" name="suphe6__s6_ilacaBaslamaTarihi" data-propertyname="s6_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe6__s6_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe6__s6_ilacinBitisTarihi" name="suphe6__s6_ilacinBitisTarihi" data-propertyname="s6_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe6__s6_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe6__s6_ilacaAraVerildiMi" name="suphe6__s6_ilacaAraVerildiMi" data-propertyname="s6_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe6__s6_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe6__s6_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe6__s6_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s6_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe6__s6_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe6__s6_ilacYenidenVerildiMi" name="suphe6__s6_ilacYenidenVerildiMi" data-propertyname="s6_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe6__s6_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe6__s6_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe6__s6_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s6_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe7"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe7__s7_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe7__s7_supheEdilenIlacAdi" name="suphe7__s7_supheEdilenIlacAdi" data-propertyname="s7_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe7__s7_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe7__s7_verilisYolu" name="suphe7__s7_verilisYolu" data-propertyname="s7_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe7__s7_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe7__s7_endikasyonu" name="suphe7__s7_endikasyonu" data-propertyname="s7_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe7__s7_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe7__s7_gunlukDozu" name="suphe7__s7_gunlukDozu" data-propertyname="s7_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe7__s7_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe7__s7_ilacaBaslamaTarihi" name="suphe7__s7_ilacaBaslamaTarihi" data-propertyname="s7_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe7__s7_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe7__s7_ilacinBitisTarihi" name="suphe7__s7_ilacinBitisTarihi" data-propertyname="s7_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe7__s7_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe7__s7_ilacaAraVerildiMi" name="suphe7__s7_ilacaAraVerildiMi" data-propertyname="s7_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe7__s7_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe7__s7_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe7__s7_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s7_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe7__s7_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe7__s7_ilacYenidenVerildiMi" name="suphe7__s7_ilacYenidenVerildiMi" data-propertyname="s7_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe7__s7_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe7__s7_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe7__s7_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s7_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe8"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe8__s8_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe8__s8_supheEdilenIlacAdi" name="suphe8__s8_supheEdilenIlacAdi" data-propertyname="s8_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe8__s8_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe8__s8_verilisYolu" name="suphe8__s8_verilisYolu" data-propertyname="s8_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe8__s8_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe8__s8_endikasyonu" name="suphe8__s8_endikasyonu" data-propertyname="s8_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe8__s8_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe8__s8_gunlukDozu" name="suphe8__s8_gunlukDozu" data-propertyname="s8_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe8__s8_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe8__s8_ilacaBaslamaTarihi" name="suphe8__s8_ilacaBaslamaTarihi" data-propertyname="s8_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe8__s8_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe8__s8_ilacinBitisTarihi" name="suphe8__s8_ilacinBitisTarihi" data-propertyname="s8_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe8__s8_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe8__s8_ilacaAraVerildiMi" name="suphe8__s8_ilacaAraVerildiMi" data-propertyname="s8_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe8__s8_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe8__s8_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe8__s8_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s8_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe8__s8_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe8__s8_ilacYenidenVerildiMi" name="suphe8__s8_ilacYenidenVerildiMi" data-propertyname="s8_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe8__s8_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe8__s8_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe8__s8_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s8_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe9"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe9__s9_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe9__s9_supheEdilenIlacAdi" name="suphe9__s9_supheEdilenIlacAdi" data-propertyname="s9_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe9__s9_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe9__s9_verilisYolu" name="suphe9__s9_verilisYolu" data-propertyname="s9_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe9__s9_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe9__s9_endikasyonu" name="suphe9__s9_endikasyonu" data-propertyname="s9_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe9__s9_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe9__s9_gunlukDozu" name="suphe9__s9_gunlukDozu" data-propertyname="s9_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe9__s9_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe9__s9_ilacaBaslamaTarihi" name="suphe9__s9_ilacaBaslamaTarihi" data-propertyname="s9_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe9__s9_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe9__s9_ilacinBitisTarihi" name="suphe9__s9_ilacinBitisTarihi" data-propertyname="s9_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe9__s9_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe9__s9_ilacaAraVerildiMi" name="suphe9__s9_ilacaAraVerildiMi" data-propertyname="s9_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe9__s9_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe9__s9_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe9__s9_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s9_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe9__s9_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe9__s9_ilacYenidenVerildiMi" name="suphe9__s9_ilacYenidenVerildiMi" data-propertyname="s9_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe9__s9_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe9__s9_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe9__s9_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s9_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-suspicions state--passive" data-prefix="suphe10"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="suphe10__s10_supheEdilenIlacAdi" class="form__label">艦眉phe Edilen 陌lac谋n Ad谋*</label> <input id="suphe10__s10_supheEdilenIlacAdi" name="suphe10__s10_supheEdilenIlacAdi" data-propertyname="s10_supheEdilenIlacAdi" type="text" class="form__input" placeholder="艦眉phe Edilen 陌lac谋n Ad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--right"> <label for="suphe10__s10_verilisYolu" class="form__label">Verili艧 Yolu*</label> <input id="suphe10__s10_verilisYolu" name="suphe10__s10_verilisYolu" data-propertyname="s10_verilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe10__s10_endikasyonu" class="form__label">Endikasyonu</label> <input id="suphe10__s10_endikasyonu" name="suphe10__s10_endikasyonu" data-propertyname="s10_endikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="suphe10__s10_gunlukDozu" class="form__label">G眉nl眉k Doz*</label> <input id="suphe10__s10_gunlukDozu" name="suphe10__s10_gunlukDozu" data-propertyname="s10_gunlukDozu" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" required="required" /> </div> <div class="form__group group--half group--left"> <label for="suphe10__s10_ilacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="suphe10__s10_ilacaBaslamaTarihi" name="suphe10__s10_ilacaBaslamaTarihi" data-propertyname="s10_ilacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="suphe10__s10_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="suphe10__s10_ilacinBitisTarihi" name="suphe10__s10_ilacinBitisTarihi" data-propertyname="s10_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--left"> <label for="suphe10__s10_ilacaAraVerildiMi" class="form__label">陌laca Ara Verildi Mi?</label> <select id="suphe10__s10_ilacaAraVerildiMi" name="suphe10__s10_ilacaAraVerildiMi" data-propertyname="s10_ilacaAraVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌laca Ara Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe10__s10_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__label">Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?</label> <select id="suphe10__s10_ilacaAraVerilinceReaksiyonAzaldiMi" name="suphe10__s10_ilacaAraVerilinceReaksiyonAzaldiMi" data-propertyname="s10_ilacaAraVerilinceReaksiyonAzaldiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Ara Verince/Doz Azalt谋l谋nca Advers Reaksiyon Azald谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--left"> <label for="suphe10__s10_ilacYenidenVerildiMi" class="form__label">陌la莽 Yeniden Verildi Mi?</label> <select id="suphe10__s10_ilacYenidenVerildiMi" name="suphe10__s10_ilacYenidenVerildiMi" data-propertyname="s10_ilacYenidenVerildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--select group--half group--right"> <label for="suphe10__s10_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__label">陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?</label> <select id="suphe10__s10_ilacYenidenVerilinceReaksiyonTekrarlandiMi" name="suphe10__s10_ilacYenidenVerilinceReaksiyonTekrarlandiMi" data-propertyname="s10_ilacYenidenVerilinceReaksiyonTekrarlandiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="陌la莽 Yeniden Verilince Advers Reaksiyon Tekrarlad谋 M谋?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> </div> <div class="form__group group--add js-adverse-form-add"> <button type="button" class="js-adverse-form-add-button" data-selector=".js-adverse-form-suspicions"> <span>陌la莽 Ekle</span> <i class="icon-plus"></i> </button> </div> <div class="form__group group--divider"></div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous " data-prefix="esZamanli1"> <div class="form__group group--half group--left"> <label for="esZamanli1__e1_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli1__e1_esZamanliKullanilanIlac" name="esZamanli1__e1_esZamanliKullanilanIlac" data-propertyname="e1_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli1__e1_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli1__e1_esZamanliKullanilanVerilisYolu" name="esZamanli1__e1_esZamanliKullanilanVerilisYolu" data-propertyname="e1_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli1__e1_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli1__e1_esZamanliKullanilanEndikasyonu" name="esZamanli1__e1_esZamanliKullanilanEndikasyonu" data-propertyname="e1_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli1__e1_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli1__e1_esZamanliKullanilanGunlukDoz" name="esZamanli1__e1_esZamanliKullanilanGunlukDoz" data-propertyname="e1_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli1__e1_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli1__e1_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli1__e1_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e1_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli1__e1_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli1__e1_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli1__e1_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e1_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli2"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli2__e2_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli2__e2_esZamanliKullanilanIlac" name="esZamanli2__e2_esZamanliKullanilanIlac" data-propertyname="e2_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli2__e2_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli2__e2_esZamanliKullanilanVerilisYolu" name="esZamanli2__e2_esZamanliKullanilanVerilisYolu" data-propertyname="e2_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli2__e2_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli2__e2_esZamanliKullanilanEndikasyonu" name="esZamanli2__e2_esZamanliKullanilanEndikasyonu" data-propertyname="e2_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli2__e2_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli2__e2_esZamanliKullanilanGunlukDoz" name="esZamanli2__e2_esZamanliKullanilanGunlukDoz" data-propertyname="e2_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli2__e2_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli2__e2_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli2__e2_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e2_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli2__e2_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli2__e2_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli2__e2_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e2_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli3"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli3__e3_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli3__e3_esZamanliKullanilanIlac" name="esZamanli3__e3_esZamanliKullanilanIlac" data-propertyname="e3_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli3__e3_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli3__e3_esZamanliKullanilanVerilisYolu" name="esZamanli3__e3_esZamanliKullanilanVerilisYolu" data-propertyname="e3_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli3__e3_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli3__e3_esZamanliKullanilanEndikasyonu" name="esZamanli3__e3_esZamanliKullanilanEndikasyonu" data-propertyname="e3_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli3__e3_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli3__e3_esZamanliKullanilanGunlukDoz" name="esZamanli3__e3_esZamanliKullanilanGunlukDoz" data-propertyname="e3_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli3__e3_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli3__e3_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli3__e3_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e3_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli3__e3_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli3__e3_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli3__e3_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e3_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli4"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli4__e4_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli4__e4_esZamanliKullanilanIlac" name="esZamanli4__e4_esZamanliKullanilanIlac" data-propertyname="e4_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli4__e4_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli4__e4_esZamanliKullanilanVerilisYolu" name="esZamanli4__e4_esZamanliKullanilanVerilisYolu" data-propertyname="e4_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli4__e4_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli4__e4_esZamanliKullanilanEndikasyonu" name="esZamanli4__e4_esZamanliKullanilanEndikasyonu" data-propertyname="e4_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli4__e4_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli4__e4_esZamanliKullanilanGunlukDoz" name="esZamanli4__e4_esZamanliKullanilanGunlukDoz" data-propertyname="e4_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli4__e4_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli4__e4_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli4__e4_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e4_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli4__e4_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli4__e4_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli4__e4_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e4_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli5"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli5__e5_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli5__e5_esZamanliKullanilanIlac" name="esZamanli5__e5_esZamanliKullanilanIlac" data-propertyname="e5_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli5__e5_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli5__e5_esZamanliKullanilanVerilisYolu" name="esZamanli5__e5_esZamanliKullanilanVerilisYolu" data-propertyname="e5_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli5__e5_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli5__e5_esZamanliKullanilanEndikasyonu" name="esZamanli5__e5_esZamanliKullanilanEndikasyonu" data-propertyname="e5_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli5__e5_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli5__e5_esZamanliKullanilanGunlukDoz" name="esZamanli5__e5_esZamanliKullanilanGunlukDoz" data-propertyname="e5_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli5__e5_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli5__e5_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli5__e5_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e5_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli5__e5_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli5__e5_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli5__e5_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e5_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli6"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli6__e6_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli6__e6_esZamanliKullanilanIlac" name="esZamanli6__e6_esZamanliKullanilanIlac" data-propertyname="e6_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli6__e6_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli6__e6_esZamanliKullanilanVerilisYolu" name="esZamanli6__e6_esZamanliKullanilanVerilisYolu" data-propertyname="e6_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli6__e6_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli6__e6_esZamanliKullanilanEndikasyonu" name="esZamanli6__e6_esZamanliKullanilanEndikasyonu" data-propertyname="e6_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli6__e6_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli6__e6_esZamanliKullanilanGunlukDoz" name="esZamanli6__e6_esZamanliKullanilanGunlukDoz" data-propertyname="e6_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli6__e6_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli6__e6_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli6__e6_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e6_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli6__e6_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli6__e6_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli6__e6_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e6_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli7"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli7__e7_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli7__e7_esZamanliKullanilanIlac" name="esZamanli7__e7_esZamanliKullanilanIlac" data-propertyname="e7_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli7__e7_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli7__e7_esZamanliKullanilanVerilisYolu" name="esZamanli7__e7_esZamanliKullanilanVerilisYolu" data-propertyname="e7_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli7__e7_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli7__e7_esZamanliKullanilanEndikasyonu" name="esZamanli7__e7_esZamanliKullanilanEndikasyonu" data-propertyname="e7_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli7__e7_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli7__e7_esZamanliKullanilanGunlukDoz" name="esZamanli7__e7_esZamanliKullanilanGunlukDoz" data-propertyname="e7_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli7__e7_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli7__e7_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli7__e7_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e7_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli7__e7_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli7__e7_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli7__e7_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e7_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli8"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli8__e8_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli8__e8_esZamanliKullanilanIlac" name="esZamanli8__e8_esZamanliKullanilanIlac" data-propertyname="e8_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli8__e8_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli8__e8_esZamanliKullanilanVerilisYolu" name="esZamanli8__e8_esZamanliKullanilanVerilisYolu" data-propertyname="e8_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli8__e8_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli8__e8_esZamanliKullanilanEndikasyonu" name="esZamanli8__e8_esZamanliKullanilanEndikasyonu" data-propertyname="e8_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli8__e8_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli8__e8_esZamanliKullanilanGunlukDoz" name="esZamanli8__e8_esZamanliKullanilanGunlukDoz" data-propertyname="e8_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli8__e8_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli8__e8_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli8__e8_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e8_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli8__e8_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli8__e8_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli8__e8_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e8_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli9"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli9__e9_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli9__e9_esZamanliKullanilanIlac" name="esZamanli9__e9_esZamanliKullanilanIlac" data-propertyname="e9_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 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<div class="form__group group--half group--right"> <label for="esZamanli9__e9_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli9__e9_esZamanliKullanilanGunlukDoz" name="esZamanli9__e9_esZamanliKullanilanGunlukDoz" data-propertyname="e9_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli9__e9_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli9__e9_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli9__e9_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e9_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli9__e9_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli9__e9_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli9__e9_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e9_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--duplicate group--zero js-adverse-form-simultaneous state--passive" data-prefix="esZamanli10"> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="esZamanli10__e10_esZamanliKullanilanIlac" class="form__label">E艧 Zamanl谋 Kullan谋lan 陌la莽</label> <input id="esZamanli10__e10_esZamanliKullanilanIlac" name="esZamanli10__e10_esZamanliKullanilanIlac" data-propertyname="e10_esZamanliKullanilanIlac" type="text" class="form__input" placeholder="E艧 Zamanl谋 Kullan谋lan 陌la莽" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli10__e10_esZamanliKullanilanVerilisYolu" class="form__label">Verili艧 Yolu</label> <input id="esZamanli10__e10_esZamanliKullanilanVerilisYolu" name="esZamanli10__e10_esZamanliKullanilanVerilisYolu" data-propertyname="e10_esZamanliKullanilanVerilisYolu" type="text" class="form__input" placeholder="Verili艧 Yolu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli10__e10_esZamanliKullanilanEndikasyonu" class="form__label">Endikasyonu</label> <input id="esZamanli10__e10_esZamanliKullanilanEndikasyonu" name="esZamanli10__e10_esZamanliKullanilanEndikasyonu" data-propertyname="e10_esZamanliKullanilanEndikasyonu" type="text" class="form__input" placeholder="Endikasyonu" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli10__e10_esZamanliKullanilanGunlukDoz" class="form__label">G眉nl眉k Doz</label> <input id="esZamanli10__e10_esZamanliKullanilanGunlukDoz" name="esZamanli10__e10_esZamanliKullanilanGunlukDoz" data-propertyname="e10_esZamanliKullanilanGunlukDoz" type="text" class="form__input" placeholder="G眉nl眉k Doz" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group group--half group--left"> <label for="esZamanli10__e10_esZamanliKullanilanIlacaBaslamaTarihi" class="form__label">陌laca Ba艧lama Tarihi</label> <input id="esZamanli10__e10_esZamanliKullanilanIlacaBaslamaTarihi" name="esZamanli10__e10_esZamanliKullanilanIlacaBaslamaTarihi" data-propertyname="e10_esZamanliKullanilanIlacaBaslamaTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--half group--right"> <label for="esZamanli10__e10_esZamanliKullanilanIlacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="esZamanli10__e10_esZamanliKullanilanIlacinBitisTarihi" name="esZamanli10__e10_esZamanliKullanilanIlacinBitisTarihi" data-propertyname="e10_esZamanliKullanilanIlacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> </div> <div class="form__group group--add js-adverse-form-add"> <button type="button" class="js-adverse-form-add-button" data-selector=".js-adverse-form-simultaneous"> <span>陌la莽 Ekle</span> <i class="icon-plus"></i> </button> </div> <div class="form__group group--divider"></div> <div class="form__group group--half group--left"> <label for="digerGozlemlerVeYorumlar" class="form__label">Di臒er G枚zlemler ve Yorum</label> <textarea id="digerGozlemlerVeYorumlar" name="digerGozlemlerVeYorumlar" class="form__textarea scrollbar--secondary" placeholder="Kullan谋lan Be艧eri T谋bbi 脺r眉n眉n Kalitesi ile 陌lgili Bir Sorundan 艦眉phe Ediliyor ise; L眉tfen 艦眉phe Edilen 脺r眉n眉n Seri Numaras谋 ve Son Kullanma Tarihi ile Birlikte Bu Sorunu Belirtiniz." spellcheck="false" rows="8" autocomplete="off" maxlength="1000" minlength="10"></textarea> </div> <div class="form__group group--half group--right"> <label for="adversReaksiyonunTedavisi" class="form__label">Advers Reaksiyonun Tedavisi</label> <textarea id="adversReaksiyonunTedavisi" name="adversReaksiyonunTedavisi" class="form__textarea scrollbar--secondary" placeholder="Tedavi i莽in kullan谋lan ila莽lar ve kullan谋m tarih (G眉n/Ay/Y谋l) leriyle birlikte" spellcheck="false" rows="8" autocomplete="off" maxlength="1000" minlength="10"></textarea> </div> <div class="form__group group--info"> <p class="form__info"> <i class="form__info__icon icon-info-circle"></i> <span class="form__info__text">Doldurulmas谋 zorunlu alanlar <b>*</b> ile belirtilmi艧tir.</span> </p> </div> <div class="form__group group--divider"></div> <div class="form__group group--submit group--half group--left order-2 order-lg-1"> <button type="button" class="button button--primary button--full js-adverse-button-gotoprev"> <span>Geri D枚n</span> </button> </div> <div class="form__group group--submit group--half group--right order-1 order-lg-2"> <button type="button" class="button button--secondary button--full js-adverse-button-validate js-adverse-button-step3"> <span>Devam Et</span> </button> </div> </div> <div class="adverse__form form js-adverse-form js-adverse-form-step4 state--passive"> <div class="form__group"> <h2 class="form__group__title">Bildirim Yapan Ki艧iye Ait Bilgiler</h2> </div> <div class="form__group group--half group--left"> <label for="bildirimYapan_adiSoyadi" class="form__label">Ad谋 Soyad谋*</label> <input id="bildirimYapan_adiSoyadi" name="bildirimYapan_adiSoyadi" type="text" class="form__input" placeholder="Ad谋 Soyad谋" spellcheck="false" autocomplete="off" minlength="3" maxlength="50" required="required" /> </div> <div class="form__group group--half group--right"> <label for="bildirimYapan_meslek" class="form__label">Meslek</label> <input id="bildirimYapan_meslek" name="bildirimYapan_meslek" type="text" class="form__input" placeholder="Meslek" spellcheck="false" autocomplete="off" minlength="3" maxlength="50" /> </div> <div class="form__group group--half group--left"> <label for="bildirimYapan_telefon" class="form__label">Telefon Numaras谋*</label> <input id="bildirimYapan_telefon" name="bildirimYapan_telefon" type="tel" class="form__input validator-phone" placeholder="Telefon Numaras谋" spellcheck="false" autocomplete="off" data-inputmask="'mask':'(999)999-99-99'" required="required" /> </div> <div class="form__group group--half group--right"> <label for="bildirimYapan_eposta" class="form__label">E-Posta</label> <input id="bildirimYapan_eposta" name="bildirimYapan_eposta" type="email" class="form__input" placeholder="E-Posta" spellcheck="false" autocomplete="off" minlength="3" maxlength="100" /> </div> <div class="form__group"> <label for="bildirimYapan_adres" class="form__label">Adresi</label> <input id="bildirimYapan_adres" name="bildirimYapan_adres" type="text" class="form__input" placeholder="Adresi" spellcheck="false" autocomplete="off" minlength="5" maxlength="250" /> </div> <div class="form__group group--half group--left"> <label for="bildirimYapan_faks" class="form__label">Faks Numaras谋</label> <input id="bildirimYapan_faks" name="bildirimYapan_faks" type="tel" class="form__input validator-phone" placeholder="Faks Numaras谋" spellcheck="false" autocomplete="off" data-inputmask="'mask':'(999)999-99-99'" /> </div> <div class="form__group group--select group--half group--right"> <label for="bildirimYapan_raporFirmayaBildirildiMi" class="form__label">Rapor Firmaya Bildirildi Mi?</label> <select id="bildirimYapan_raporFirmayaBildirildiMi" name="bildirimYapan_raporFirmayaBildirildiMi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Rapor Firmaya Bildirildi Mi?" data-search="false"> <option hidden value=""></option> <option value="Evet">Evet</option> <option value="Hay谋r">Hay谋r</option> <option value="Bilinmiyor">Bilinmiyor</option> </select> </div> <div class="form__group group--half group--left"> <label for="bildirimYapan_ilacinBitisTarihi" class="form__label">陌lac谋n Biti艧 Tarihi</label> <input id="bildirimYapan_ilacinBitisTarihi" name="bildirimYapan_ilacinBitisTarihi" type="text" class="form__input" placeholder="G眉n/Ay/Y谋l" data-inputmask="'mask':'99/99/9999'" spellcheck="false" autocomplete="off" minlength="10" maxlength="10" /> </div> <div class="form__group group--select group--half group--right"> <label for="bildirimYapan_raporTipi" class="form__label">Rapor Tipi</label> <select id="bildirimYapan_raporTipi" name="bildirimYapan_raporTipi" class="form__select js-select2" data-theme-class="select--primary" data-placeholder="Rapor Tipi" data-search="false"> <option hidden value=""></option> <option value="陌lk">陌lk</option> <option value="Takip">Takip</option> </select> </div> <div class="form__group group--half group--left"> <label for="bildirimYapan_kayitNo" class="form__label">Kay谋t No</label> <input id="bildirimYapan_kayitNo" name="bildirimYapan_kayitNo" type="text" class="form__input" placeholder="Kay谋t No" spellcheck="false" autocomplete="off" minlength="3" maxlength="50" /> </div> <div class="form__group group--captcha group--half group--right"> <label for="captcha" class="form__label">G眉venlik Kodu*</label> <div class="form__captcha"> <input id="captcha" name="Captcha" data-name="Captcha" data-propertyname="CaptchaValidatorModel" type="text" class="form__input form__captcha__input js-captcha-input" placeholder="G眉venlik Kodu" spellcheck="false" autocomplete="off" maxlength="6" minlength="6" required="required" /> <div class="form__captcha__content"> <img id="RenderBody_PageContactFormAdverse_captchaImage" class="form__captcha__image js-captcha-image" onclick="this.src='/Captcha.ashx?uid=adverseffectsform&date='+(new Date()).getTime();" src="../Captcha.ashx?uid=adverseffectsform" alt="Captcha" /> <button type="button" class="form__captcha__button js-captcha-button" aria-label="G眉venlik Kodu"> <i class="icon-refresh" aria-hidden="true"></i> </button> </div> </div> </div> <div class="form__group group--checkbox"> <input id="bildirimYapan_kvkk" name="bildirimYapan_kvkk" type="checkbox" class="form__checkbox validator-checkbox" value="true" required="required" /> <label for="bildirimYapan_kvkk" class="form__checkbox__label form__checkbox__info"> <a target="_blank" rel="noreferrer noopener" href="/iletisim/kvkk-bilgilendirme-metni">KVKK</a> kapsam谋nda bilgilerimi payla艧may谋 kabul ediyorum.* </label> </div> <div class="form__group group--info"> <p class="form__info"> <i class="form__info__icon icon-info-circle"></i> <span class="form__info__text">Doldurulmas谋 zorunlu alanlar <b>*</b> ile belirtilmi艧tir.</span> </p> </div> <div class="form__group group--divider"></div> <div class="form__group group--submit group--half group--left order-2 order-lg-1"> <button type="button" class="button button--primary button--full js-adverse-button-gotoprev"> <span>Geri D枚n</span> </button> </div> <div class="form__group group--submit group--half group--right order-1 order-lg-2"> <button type="button" class="button button--secondary button--full js-adverse-button-validate js-adverse-button-submit"> <span>G枚nder</span> </button> </div> </div> </div> <div class="adverse__form__results form__results js-form-results"> <i class="form__results__icon icon-info-circle"></i> <h3 class="form__results__title js-form-results-title" data-success="Form ba艧ar谋yla g枚nderildi." data-error="Form g枚nderilirken hata olu艧tu."></h3> <p 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