{"id":113497,"date":"2025-11-04T16:03:26","date_gmt":"2025-11-04T15:03:26","guid":{"rendered":"https:\/\/medischecheckup.com\/?page_id=113497"},"modified":"2026-01-15T10:17:50","modified_gmt":"2026-01-15T09:17:50","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/medischecheckup.com\/en\/intake-form\/","title":{"rendered":"Intake form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div data-parent=\"true\" class=\"vc_row section-intake has-bg need-focus style-color-145652-bg row-container\" id=\"row-unique-0\"><div class=\"row single-top-padding single-bottom-padding single-h-padding limit-width row-parent\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-middle pos-center align_left align_left_mobile column_parent col-lg-12 no-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell\" ><div class=\"uncont no-block-padding col-custom-width\" style=\" max-width:69%;\" ><div class=\"empty-space empty-double tablet-hidden mobile-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap mobile_25px\"><div class=\"heading-text el-text\" ><h2 class=\"h2 font-weight-700 text-color-jevc-color\" ><span>Do the online intake and find out in a few steps what medical checkup you need<\/span><\/h2><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-quart\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap mobile_16px\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-488263 fontsize-501377 fontheight-357766 font-weight-500 text-color-jevc-color\" ><span>Personalised screening advice in less than 2 minutes.<\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"uncode_text_column\" ><form id=\"forminator-module-113046\" class=\"forminator-custom-form forminator-custom-form-113046\" method=\"post\" data-forminator-render=\"0\" data-uid=\"69e1254e198f8\" action=\"\"><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n<\/div><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"empty-space empty-double tablet-hidden mobile-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<\/div><\/div><\/div><\/div><\/div><script id=\"script-row-unique-0\" data-row=\"script-row-unique-0\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-0\"));<\/script><\/div><\/div><\/div><div data-parent=\"true\" class=\"vc_row row-container tablet-hidden mobile-hidden\" id=\"row-unique-1\"><div class=\"row no-top-padding no-bottom-padding single-h-padding limit-width row-parent\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_left column_parent col-lg-12 single-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" ><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<\/div><\/div><\/div><\/div><\/div><script id=\"script-row-unique-1\" data-row=\"script-row-unique-1\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-1\"));<\/script><\/div><\/div><\/div><div data-parent=\"true\" class=\"vc_row section-form-text row-container\" id=\"row-unique-2\"><div class=\"row double-top-padding double-bottom-padding double-h-padding full-width row-parent\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-middle pos-right align_left column_parent col-lg-6 form-text col-md-50 no-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" style=\" max-width:90%;\" ><div class=\"empty-space empty-double mobile-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_row row-internal row-container\"><div class=\"row row-child\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-left align_left column_child col-lg-12 no-internal-gutter\"><div class=\"uncol style-light\" ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" style=\" max-width:75%;\" ><div class=\"vc_custom_heading_wrap mobile_25px\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><h2 class=\"font-161437 h2 font-weight-500 text-color-jevc-color\" ><span>Contact us<\/span><\/h2><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-single tablet-hidden mobile-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"empty-space empty-half desktop-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap mobile_16px\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-488263 fontsize-168927 fontheight-357766 font-weight-500 text-color-jevc-color\" ><span>Do you have questions or want more information about Medical Checkup's services? Using the contact form below, you can easily submit your question. We are ready to answer it and provide you with all the information you need. Do not hesitate to contact us!<\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-161437 fontsize-168927 fontheight-954288 font-weight-500 text-color-169961-color\" ><span>Contact info<\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-488263 fontsize-168927 fontheight-954288 font-weight-500 text-color-169961-color\" ><span><a href=\"mailto:info@medischecheckup.com\">info@medischecheckup.com<\/a><\/p><\/span><span><p><a class=\"cursor-init\" href=\"callto:+3235352040\">+32 3 535 20 40<\/a><\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-161437 fontsize-168927 fontheight-954288 font-weight-500 text-color-169961-color\" ><span>Address<\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-488263 fontsize-168927 fontheight-954288 font-weight-500 text-color-169961-color\" ><span><\/p><\/span><span><p><a class=\"cursor-init\" href=\"https:\/\/g.co\/kgs\/gyFm8xx\" target=\"_blank\" rel=\"noopener\">Uitbreidingstraat 2-8, 2600 Antwerp<\/a><\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-161437 fontsize-168927 fontheight-954288 font-weight-500 text-color-169961-color\" ><span>Opening hours<\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-488263 fontsize-168927 fontheight-954288 font-weight-500 text-color-169961-color\" ><span>Monday - Friday<\/p><\/span><span><p>08:00 - 18:00<\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-double\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"wpb_column pos-middle pos-left align_left column_parent col-lg-6 col-md-50 single-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" style=\" max-width:95%;\" ><div class=\"vc_row row-internal row-container\"><div class=\"row row-child\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_left column_child col-lg-12 form-block one-internal-gutter\"><div class=\"uncol style-light\" ><div class=\"uncoltable\"><div class=\"uncell single-block-padding style-color-169961-bg\" ><div class=\"uncont\" style=\" max-width:80%;\" ><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap mobile_25px\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><h3 class=\"font-161437 h2 fontheight-954288 font-weight-500 text-color-xsdn-color\" ><span>Fill in your details<\/span><\/h3><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-half\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-488263 fontsize-168927 fontheight-954288 font-weight-500 text-color-xsdn-color\" ><span><div class=\"forminator-ui forminator-custom-form forminator-custom-form-112278 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-112278\" data-uid=\"69e1254e1cf1b\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-112278\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-112278 forminator-design--default  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"112278\"\r\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"69e1254e1cf1b\" action=\"\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div 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id=\"script-row-unique-2\" data-row=\"script-row-unique-2\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-2\"));<\/script><\/div><\/div><\/div><div data-parent=\"true\" class=\"vc_row row-container tablet-hidden mobile-hidden\" id=\"row-unique-3\"><div class=\"row no-top-padding no-bottom-padding single-h-padding limit-width row-parent\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_left column_parent col-lg-12 single-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" ><div class=\"empty-space empty-single\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<\/div><\/div><\/div><\/div><\/div><script id=\"script-row-unique-3\" data-row=\"script-row-unique-3\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-3\"));<\/script><\/div><\/div><\/div><div data-parent=\"true\" class=\"vc_row row-container desktop-hidden tablet-hidden mobile-hidden\" id=\"row-unique-4\"><div class=\"row no-top-padding no-bottom-padding no-h-padding full-width row-parent\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-top pos-center align_left column_parent col-lg-12 single-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell no-block-padding\" ><div class=\"uncont\" >\n\t<div class=\"wpb_raw_code wpb_raw_js\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<iframe src=\"https:\/\/snazzymaps.com\/embed\/665016\" width=\"100%\" height=\"543.5px\" style=\"border:none;\"><\/iframe>\n\t\t<\/div>\n\t<\/div>\n<\/div><\/div><\/div><\/div><\/div><script id=\"script-row-unique-4\" data-row=\"script-row-unique-4\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-4\"));<\/script><\/div><\/div><\/div><div data-parent=\"true\" class=\"vc_row section-image-quote row-container with-parallax\" id=\"row-unique-5\"><div class=\"row-background background-element\">\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"background-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"background-inner\" style=\"background-image: url(https:\/\/medischecheckup.com\/wp-content\/uploads\/2025\/11\/vitaly-gariev-dlkeCHsagmU-unsplash-scaled.jpg);background-repeat: no-repeat;background-position: center center;background-size: cover;\"><\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"block-bg-overlay style-overlay_color-941966-bg\" style=\"opacity: 0.35;\"><\/div>\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<\/div><div class=\"row no-top-padding no-bottom-padding no-h-padding full-width row-parent\" data-height-ratio=\"70\"><div class=\"wpb_row row-inner\"><div class=\"wpb_column pos-middle pos-center align_center align_center_tablet align_center_mobile column_parent col-lg-12 width_contact_quote single-internal-gutter\"><div class=\"uncol style-light\"  ><div class=\"uncoltable\"><div class=\"uncell\" ><div class=\"uncont no-block-padding col-custom-width\" style=\" max-width:60%;\" ><div class=\"empty-space empty-double desktop-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<div class=\"vc_custom_heading_wrap mobile_25px\"><div class=\"heading-text el-text alpha-anim animate_when_almost_visible\" data-delay=\"200\"><div class=\"font-188146 fontsize-208892 fontheight-357766 font-weight-500 text-color-xsdn-color\" ><span>Medical checkups provide peace of mind and can improve your quality of life.<\/span><\/div><\/div><div class=\"clear\"><\/div><\/div><div class=\"empty-space empty-double desktop-hidden\" ><span class=\"empty-space-inner\"><\/span><\/div>\n<\/div><\/div><\/div><\/div><\/div><script id=\"script-row-unique-5\" data-row=\"script-row-unique-5\" type=\"text\/javascript\" class=\"vc_controls\">UNCODE.initRow(document.getElementById(\"row-unique-5\"));<\/script><\/div><\/div><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"Do the online intake and find out in a few steps what medical checkup you need Personalised screening advice in less than 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