Doctor appointment form
Book a clinic visit. The form asks for a time and a short reason, not a diagnosis.
הטופס הזה אינו רשומה רפואית. אל תשלחו אבחנות, תוצאות בדיקות או פרטי בריאות אחרים שאינם נחוצים לפנייה. נתוני בריאות הם קטגוריה מיוחדת לפי ה-GDPR.
תצוגה מקדימה
קוד הטופס
<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title>Doctor appointment form</title>
<style>
body { font-family: "Segoe UI", sans-serif; color: #12263a; margin: 0; background: #fff; }
main { max-width: 640px; margin: 0 auto; padding: 32px 20px 64px; }
h1 { font-size: 28px; font-weight: 650; letter-spacing: -0.02em; line-height: 1.2; }
h2 { font-size: 18px; margin: 18px 0 0; }
p { line-height: 1.5; }
form { display: grid; gap: 14px; position: relative; }
.field { display: grid; gap: 6px; }
label span, .check span { font-size: 14px; }
input, select, textarea { font: inherit; color: inherit; padding: 10px 12px; border: 1px solid #b4bdce; border-radius: 8px; width: 100%; box-sizing: border-box; background: #fff; }
textarea { min-height: 96px; }
.check { display: flex; gap: 8px; align-items: flex-start; }
.check input { width: auto; margin-top: 4px; }
button { background: #3c4ad8; color: #fff; border: 0; border-radius: 8px; padding: 12px 18px; font: inherit; cursor: pointer; }
.note { background: #fff6eb; padding: 12px 14px; border-radius: 8px; }
form [data-show-if] { display: none; }
form:has(select[name="visit_for"] option[value="child"]:checked) [data-show-if="visit_for"][data-show-equals="child"] { display: grid; }
</style>
</head>
<body>
<main>
<h1 data-i18n="title">Doctor appointment form</h1>
<p data-i18n="lede">Book a clinic visit. The form asks for a time and a short reason, not a diagnosis.</p>
<p class="note" data-i18n="disclaimer">This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.</p>
<form id="fg-form" action="https://formgong.com/submit" method="POST">
<input type="hidden" name="access_key" value="fk_your_access_key">
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden"><label>Leave this field empty<input name="botcheck" tabindex="-1" autocomplete="off"></label></div>
<section><h2 data-i18n="section.visit">Visit</h2>
<div class="field"><label for="fg-service"><span data-i18n="service">What do you need?</span></label><select id="fg-service" name="service" required><option value="">—</option><option value="consultation" data-i18n="service.consultation">Consultation</option><option value="follow_up" data-i18n="service.follow_up">Follow-up</option><option value="vaccination" data-i18n="service.vaccination">Vaccination</option><option value="diagnostics" data-i18n="service.diagnostics">Tests</option></select></div>
<div class="field"><label for="fg-preferred_date"><span data-i18n="preferred_date">Preferred date</span></label><input id="fg-preferred_date" name="preferred_date" type="date" required></div>
<div class="field"><label for="fg-preferred_time"><span data-i18n="preferred_time">Preferred time</span></label><select id="fg-preferred_time" name="preferred_time" required><option value="">—</option><option value="morning" data-i18n="preferred_time.morning">Morning</option><option value="afternoon" data-i18n="preferred_time.afternoon">Afternoon</option><option value="evening" data-i18n="preferred_time.evening">Evening</option></select></div>
<div class="field"><label for="fg-visit_for"><span data-i18n="visit_for">Who is the visit for?</span></label><select id="fg-visit_for" name="visit_for" required><option value="">—</option><option value="self" data-i18n="visit_for.self">Me</option><option value="child" data-i18n="visit_for.child">A child</option></select></div>
<div class="field" data-show-if="visit_for" data-show-equals="child"><label for="fg-child_name"><span data-i18n="child_name">Child's name</span></label><input id="fg-child_name" name="child_name" type="text" maxlength="80" autocomplete="name"></div></section>
<section><h2 data-i18n="section.contact">Contact</h2>
<div class="field"><label for="fg-name"><span data-i18n="name">Name</span></label><input id="fg-name" name="name" type="text" required maxlength="80" autocomplete="name"></div>
<div class="field"><label for="fg-email"><span data-i18n="email">Email</span></label><input id="fg-email" name="email" type="email" maxlength="120" autocomplete="email"></div>
<div class="field"><label for="fg-phone"><span data-i18n="phone">Phone</span></label><input id="fg-phone" name="phone" type="tel" required maxlength="40" autocomplete="tel"></div></section>
<section><h2 data-i18n="section.reason">Reason</h2>
<div class="field"><label for="fg-reason"><span data-i18n="reason">Short reason for the visit</span></label><textarea id="fg-reason" name="reason" required maxlength="500"></textarea></div></section>
<section><h2 data-i18n="section.consent">Consent</h2>
<div class="field"><label class="check"><input id="fg-consent_contact" name="consent_contact" type="checkbox" value="yes" required><span data-i18n="consent_contact">I agree to be contacted about this request.</span></label></div>
<div class="field"><label class="check"><input id="fg-consent_privacy" name="consent_privacy" type="checkbox" value="yes" required><span data-i18n="consent_privacy">I agree that these answers are stored so the request can be handled.</span></label></div></section>
<!-- Turnstile hook: enable Turnstile on this form in Formgong, then set your site key.
<script src="https://challenges.cloudflare.com/turnstile/v0/api.js" async defer></script>
<div class="cf-turnstile" data-sitekey="YOUR_TURNSTILE_SITE_KEY"></div>
-->
<button type="submit" data-i18n="submit">Send</button>
<p data-status role="status"></p>
</form>
</main>
<script type="application/json" id="fg-labels">{"uk":{"title":"Форма запису до лікаря","lede":"Запис на візит до клініки. Форма питає час і коротку причину, не діагноз.","submit":"Надіслати","thanks":"Надіслано. Дякуємо.","file_too_big":"Файл більший за 24 КБ. Додайте посилання.","disclaimer":"Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.","section.visit":"Візит","service":"Що потрібно?","service.consultation":"Консультація","service.follow_up":"Повторний візит","service.vaccination":"Щеплення","service.diagnostics":"Обстеження","preferred_date":"Бажана дата","preferred_time":"Бажаний час","preferred_time.morning":"Ранок","preferred_time.afternoon":"День","preferred_time.evening":"Вечір","visit_for":"Для кого візит?","visit_for.self":"Для мене","visit_for.child":"Для дитини","child_name":"Ім'я дитини","section.contact":"Контакт","name":"Ім'я","email":"Електронна пошта","phone":"Телефон","section.reason":"Причина","reason":"Коротка причина візиту","section.consent":"Згода","consent_contact":"Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.","consent_privacy":"Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."},"en":{"title":"Doctor appointment form","lede":"Book a clinic visit. The form asks for a time and a short reason, not a diagnosis.","submit":"Send","thanks":"Sent. Thank you.","file_too_big":"That file is over 24 KB. Paste a link instead.","disclaimer":"This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.","section.visit":"Visit","service":"What do you need?","service.consultation":"Consultation","service.follow_up":"Follow-up","service.vaccination":"Vaccination","service.diagnostics":"Tests","preferred_date":"Preferred date","preferred_time":"Preferred time","preferred_time.morning":"Morning","preferred_time.afternoon":"Afternoon","preferred_time.evening":"Evening","visit_for":"Who is the visit for?","visit_for.self":"Me","visit_for.child":"A child","child_name":"Child's name","section.contact":"Contact","name":"Name","email":"Email","phone":"Phone","section.reason":"Reason","reason":"Short reason for the visit","section.consent":"Consent","consent_contact":"I agree to be contacted about this request.","consent_privacy":"I agree that these answers are stored so the request can be handled."},"pl":{"title":"Formularz zapisu do lekarza","lede":"Zapis na wizytę. Formularz pyta o termin i krótki powód, nie o rozpoznanie.","submit":"Wyślij","thanks":"Wysłano. Dziękujemy.","file_too_big":"Plik ma ponad 24 KB. Wklej link.","disclaimer":"Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.","section.visit":"Wizyta","service":"Czego dotyczy wizyta?","service.consultation":"Konsultacja","service.follow_up":"Wizyta kontrolna","service.vaccination":"Szczepienie","service.diagnostics":"Badania","preferred_date":"Preferowana data","preferred_time":"Preferowana pora","preferred_time.morning":"Rano","preferred_time.afternoon":"Popołudnie","preferred_time.evening":"Wieczór","visit_for":"Dla kogo jest wizyta?","visit_for.self":"Dla mnie","visit_for.child":"Dla dziecka","child_name":"Imię dziecka","section.contact":"Kontakt","name":"Imię","email":"E-mail","phone":"Telefon","section.reason":"Powód","reason":"Krótki powód wizyty","section.consent":"Zgoda","consent_contact":"Zgadzam się na kontakt w sprawie tego zgłoszenia.","consent_privacy":"Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."},"tr":{"title":"Doktor randevu formu","lede":"Klinik ziyareti için randevu. Form saat ve kısa bir neden sorar, tanı değil.","submit":"Gönder","thanks":"Gönderildi. Teşekkürler.","file_too_big":"Dosya 24 KB'den büyük. Bağlantı ekleyin.","disclaimer":"Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.","section.visit":"Ziyaret","service":"Ne için geliyorsunuz?","service.consultation":"Muayene","service.follow_up":"Kontrol","service.vaccination":"Aşı","service.diagnostics":"Tetkik","preferred_date":"Tercih edilen tarih","preferred_time":"Tercih edilen saat","preferred_time.morning":"Sabah","preferred_time.afternoon":"Öğleden sonra","preferred_time.evening":"Akşam","visit_for":"Randevu kimin için?","visit_for.self":"Benim için","visit_for.child":"Çocuk için","child_name":"Çocuğun adı","section.contact":"İletişim","name":"Ad","email":"E-posta","phone":"Telefon","section.reason":"Neden","reason":"Ziyaretin kısa nedeni","section.consent":"Onay","consent_contact":"Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.","consent_privacy":"Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."}}</script>
<script>
(function () {
var MAX = 24576;
var form = document.getElementById("fg-form");
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apply();
var status = form.querySelector("[data-status]");
form.addEventListener("submit", function (event) {
event.preventDefault();
var dict = pack[code()];
var body = {};
var files = [];
new FormData(form).forEach(function (value, key) {
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if (status) status.textContent = dict.file_too_big;
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return readFile(pair[1]).then(function (data) {
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body[pair[0] + "_data"] = data;
});
})).then(function () {
return fetch(form.action, {
method: "POST",
headers: { "Content-Type": "application/json", Accept: "application/json" },
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}).then(function (response) { return response.json(); }).then(function (result) {
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</body>
</html>
// Generated from src/content/industries.ts — npm run templates:write
import { useState } from "react";
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 24576;
const LABELS = {
"uk": {
"title": "Форма запису до лікаря",
"lede": "Запис на візит до клініки. Форма питає час і коротку причину, не діагноз.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "Файл більший за 24 КБ. Додайте посилання.",
"disclaimer": "Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.",
"section.visit": "Візит",
"service": "Що потрібно?",
"service.consultation": "Консультація",
"service.follow_up": "Повторний візит",
"service.vaccination": "Щеплення",
"service.diagnostics": "Обстеження",
"preferred_date": "Бажана дата",
"preferred_time": "Бажаний час",
"preferred_time.morning": "Ранок",
"preferred_time.afternoon": "День",
"preferred_time.evening": "Вечір",
"visit_for": "Для кого візит?",
"visit_for.self": "Для мене",
"visit_for.child": "Для дитини",
"child_name": "Ім'я дитини",
"section.contact": "Контакт",
"name": "Ім'я",
"email": "Електронна пошта",
"phone": "Телефон",
"section.reason": "Причина",
"reason": "Коротка причина візиту",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Doctor appointment form",
"lede": "Book a clinic visit. The form asks for a time and a short reason, not a diagnosis.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "That file is over 24 KB. Paste a link instead.",
"disclaimer": "This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.",
"section.visit": "Visit",
"service": "What do you need?",
"service.consultation": "Consultation",
"service.follow_up": "Follow-up",
"service.vaccination": "Vaccination",
"service.diagnostics": "Tests",
"preferred_date": "Preferred date",
"preferred_time": "Preferred time",
"preferred_time.morning": "Morning",
"preferred_time.afternoon": "Afternoon",
"preferred_time.evening": "Evening",
"visit_for": "Who is the visit for?",
"visit_for.self": "Me",
"visit_for.child": "A child",
"child_name": "Child's name",
"section.contact": "Contact",
"name": "Name",
"email": "Email",
"phone": "Phone",
"section.reason": "Reason",
"reason": "Short reason for the visit",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz zapisu do lekarza",
"lede": "Zapis na wizytę. Formularz pyta o termin i krótki powód, nie o rozpoznanie.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Plik ma ponad 24 KB. Wklej link.",
"disclaimer": "Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.",
"section.visit": "Wizyta",
"service": "Czego dotyczy wizyta?",
"service.consultation": "Konsultacja",
"service.follow_up": "Wizyta kontrolna",
"service.vaccination": "Szczepienie",
"service.diagnostics": "Badania",
"preferred_date": "Preferowana data",
"preferred_time": "Preferowana pora",
"preferred_time.morning": "Rano",
"preferred_time.afternoon": "Popołudnie",
"preferred_time.evening": "Wieczór",
"visit_for": "Dla kogo jest wizyta?",
"visit_for.self": "Dla mnie",
"visit_for.child": "Dla dziecka",
"child_name": "Imię dziecka",
"section.contact": "Kontakt",
"name": "Imię",
"email": "E-mail",
"phone": "Telefon",
"section.reason": "Powód",
"reason": "Krótki powód wizyty",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Doktor randevu formu",
"lede": "Klinik ziyareti için randevu. Form saat ve kısa bir neden sorar, tanı değil.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "Dosya 24 KB'den büyük. Bağlantı ekleyin.",
"disclaimer": "Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.",
"section.visit": "Ziyaret",
"service": "Ne için geliyorsunuz?",
"service.consultation": "Muayene",
"service.follow_up": "Kontrol",
"service.vaccination": "Aşı",
"service.diagnostics": "Tetkik",
"preferred_date": "Tercih edilen tarih",
"preferred_time": "Tercih edilen saat",
"preferred_time.morning": "Sabah",
"preferred_time.afternoon": "Öğleden sonra",
"preferred_time.evening": "Akşam",
"visit_for": "Randevu kimin için?",
"visit_for.self": "Benim için",
"visit_for.child": "Çocuk için",
"child_name": "Çocuğun adı",
"section.contact": "İletişim",
"name": "Ad",
"email": "E-posta",
"phone": "Telefon",
"section.reason": "Neden",
"reason": "Ziyaretin kısa nedeni",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
export function IndustryForm({ lang = "en", accessKey = "fk_your_access_key" }) {
const t = LABELS[lang] || LABELS.en;
const [status, setStatus] = useState("");
const [values, setValues] = useState({ visit_for: "" });
function setField(name, value) {
setValues((current) => ({ ...current, [name]: value }));
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = {};
const files = [];
for (const [key, value] of new FormData(form).entries()) {
if (value instanceof File) {
if (value.size) files.push([key, value]);
continue;
}
body[key] = String(value);
}
if (files.some((pair) => pair[1].size > FILE_MAX)) {
setStatus(t.file_too_big);
return;
}
for (const [key, file] of files) {
body[key + "_filename"] = file.name;
body[key + "_data"] = await readFile(file);
}
const response = await fetch(ENDPOINT, {
method: "POST",
headers: { "Content-Type": "application/json", Accept: "application/json" },
body: JSON.stringify(body),
});
const result = await response.json();
setStatus(result.success ? t.thanks : (result.message || "error"));
}
return (
<form onSubmit={onSubmit}>
<h1>{t.title}</h1>
<p>{t.lede}</p>
{t.disclaimer ? <p>{t.disclaimer}</p> : null}
<input type="hidden" name="access_key" value={accessKey} />
<div aria-hidden="true" style={{ position: "absolute", left: "-10000px", width: 1, height: 1, overflow: "hidden" }}>
<input name="botcheck" tabIndex={-1} autoComplete="off" />
</div>
<section><h2>{t["section.visit"]}</h2>
<label><span>{t["service"]}</span><select name="service" required><option value="">—</option><option value="consultation">{t["service.consultation"]}</option><option value="follow_up">{t["service.follow_up"]}</option><option value="vaccination">{t["service.vaccination"]}</option><option value="diagnostics">{t["service.diagnostics"]}</option></select></label>
<label><span>{t["preferred_date"]}</span><input name="preferred_date" type="date" required /></label>
<label><span>{t["preferred_time"]}</span><select name="preferred_time" required><option value="">—</option><option value="morning">{t["preferred_time.morning"]}</option><option value="afternoon">{t["preferred_time.afternoon"]}</option><option value="evening">{t["preferred_time.evening"]}</option></select></label>
<label><span>{t["visit_for"]}</span><select name="visit_for" required value={values["visit_for"]} onChange={(event) => setField("visit_for", event.target.value)}><option value="">—</option><option value="self">{t["visit_for.self"]}</option><option value="child">{t["visit_for.child"]}</option></select></label>
{values["visit_for"] === "child" ? (<label><span>{t["child_name"]}</span><input name="child_name" type="text" maxLength={80} autoComplete="name" /></label>) : null}</section>
<section><h2>{t["section.contact"]}</h2>
<label><span>{t["name"]}</span><input name="name" type="text" required maxLength={80} autoComplete="name" /></label>
<label><span>{t["email"]}</span><input name="email" type="email" maxLength={120} autoComplete="email" /></label>
<label><span>{t["phone"]}</span><input name="phone" type="tel" required maxLength={40} autoComplete="tel" /></label></section>
<section><h2>{t["section.reason"]}</h2>
<label><span>{t["reason"]}</span><textarea name="reason" required maxLength={500} /></label></section>
<section><h2>{t["section.consent"]}</h2>
<label className="check"><input name="consent_contact" type="checkbox" value="yes" required /><span>{t["consent_contact"]}</span></label>
<label className="check"><input name="consent_privacy" type="checkbox" value="yes" required /><span>{t["consent_privacy"]}</span></label></section>
{/* Turnstile hook: enable Turnstile on this form in Formgong, load https://challenges.cloudflare.com/turnstile/v0/api.js, and render <div className="cf-turnstile" data-sitekey="YOUR_TURNSTILE_SITE_KEY" /> */}
<button type="submit">{t.submit}</button>
<p>{status}</p>
</form>
);
}
function readFile(file) {
return new Promise((resolve, reject) => {
const reader = new FileReader();
reader.onload = () => {
const raw = String(reader.result || "");
const comma = raw.indexOf(",");
resolve(comma === -1 ? raw : raw.slice(comma + 1));
};
reader.onerror = () => reject(reader.error);
reader.readAsDataURL(file);
});
}
<!-- Generated from src/content/industries.ts — npm run templates:write -->
<script setup>
import { reactive, ref, computed } from "vue";
const props = defineProps({
lang: { type: String, default: "en" },
accessKey: { type: String, default: "fk_your_access_key" },
});
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 24576;
const LABELS = {
"uk": {
"title": "Форма запису до лікаря",
"lede": "Запис на візит до клініки. Форма питає час і коротку причину, не діагноз.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "Файл більший за 24 КБ. Додайте посилання.",
"disclaimer": "Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.",
"section.visit": "Візит",
"service": "Що потрібно?",
"service.consultation": "Консультація",
"service.follow_up": "Повторний візит",
"service.vaccination": "Щеплення",
"service.diagnostics": "Обстеження",
"preferred_date": "Бажана дата",
"preferred_time": "Бажаний час",
"preferred_time.morning": "Ранок",
"preferred_time.afternoon": "День",
"preferred_time.evening": "Вечір",
"visit_for": "Для кого візит?",
"visit_for.self": "Для мене",
"visit_for.child": "Для дитини",
"child_name": "Ім'я дитини",
"section.contact": "Контакт",
"name": "Ім'я",
"email": "Електронна пошта",
"phone": "Телефон",
"section.reason": "Причина",
"reason": "Коротка причина візиту",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Doctor appointment form",
"lede": "Book a clinic visit. The form asks for a time and a short reason, not a diagnosis.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "That file is over 24 KB. Paste a link instead.",
"disclaimer": "This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.",
"section.visit": "Visit",
"service": "What do you need?",
"service.consultation": "Consultation",
"service.follow_up": "Follow-up",
"service.vaccination": "Vaccination",
"service.diagnostics": "Tests",
"preferred_date": "Preferred date",
"preferred_time": "Preferred time",
"preferred_time.morning": "Morning",
"preferred_time.afternoon": "Afternoon",
"preferred_time.evening": "Evening",
"visit_for": "Who is the visit for?",
"visit_for.self": "Me",
"visit_for.child": "A child",
"child_name": "Child's name",
"section.contact": "Contact",
"name": "Name",
"email": "Email",
"phone": "Phone",
"section.reason": "Reason",
"reason": "Short reason for the visit",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz zapisu do lekarza",
"lede": "Zapis na wizytę. Formularz pyta o termin i krótki powód, nie o rozpoznanie.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Plik ma ponad 24 KB. Wklej link.",
"disclaimer": "Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.",
"section.visit": "Wizyta",
"service": "Czego dotyczy wizyta?",
"service.consultation": "Konsultacja",
"service.follow_up": "Wizyta kontrolna",
"service.vaccination": "Szczepienie",
"service.diagnostics": "Badania",
"preferred_date": "Preferowana data",
"preferred_time": "Preferowana pora",
"preferred_time.morning": "Rano",
"preferred_time.afternoon": "Popołudnie",
"preferred_time.evening": "Wieczór",
"visit_for": "Dla kogo jest wizyta?",
"visit_for.self": "Dla mnie",
"visit_for.child": "Dla dziecka",
"child_name": "Imię dziecka",
"section.contact": "Kontakt",
"name": "Imię",
"email": "E-mail",
"phone": "Telefon",
"section.reason": "Powód",
"reason": "Krótki powód wizyty",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Doktor randevu formu",
"lede": "Klinik ziyareti için randevu. Form saat ve kısa bir neden sorar, tanı değil.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "Dosya 24 KB'den büyük. Bağlantı ekleyin.",
"disclaimer": "Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.",
"section.visit": "Ziyaret",
"service": "Ne için geliyorsunuz?",
"service.consultation": "Muayene",
"service.follow_up": "Kontrol",
"service.vaccination": "Aşı",
"service.diagnostics": "Tetkik",
"preferred_date": "Tercih edilen tarih",
"preferred_time": "Tercih edilen saat",
"preferred_time.morning": "Sabah",
"preferred_time.afternoon": "Öğleden sonra",
"preferred_time.evening": "Akşam",
"visit_for": "Randevu kimin için?",
"visit_for.self": "Benim için",
"visit_for.child": "Çocuk için",
"child_name": "Çocuğun adı",
"section.contact": "İletişim",
"name": "Ad",
"email": "E-posta",
"phone": "Telefon",
"section.reason": "Neden",
"reason": "Ziyaretin kısa nedeni",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
const t = computed(() => LABELS[props.lang] || LABELS.en);
const status = ref("");
const values = reactive({ visit_for: "" });
function readFile(file) {
return new Promise((resolve, reject) => {
const reader = new FileReader();
reader.onload = () => {
const raw = String(reader.result || "");
const comma = raw.indexOf(",");
resolve(comma === -1 ? raw : raw.slice(comma + 1));
};
reader.onerror = () => reject(reader.error);
reader.readAsDataURL(file);
});
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = {};
const files = [];
for (const [key, value] of new FormData(form).entries()) {
if (value instanceof File) {
if (value.size) files.push([key, value]);
continue;
}
body[key] = String(value);
}
if (files.some((pair) => pair[1].size > FILE_MAX)) {
status.value = t.value.file_too_big;
return;
}
for (const [key, file] of files) {
body[key + "_filename"] = file.name;
body[key + "_data"] = await readFile(file);
}
const response = await fetch(ENDPOINT, {
method: "POST",
headers: { "Content-Type": "application/json", Accept: "application/json" },
body: JSON.stringify(body),
});
const result = await response.json();
status.value = result.success ? t.value.thanks : (result.message || "error");
}
</script>
<template>
<form @submit.prevent="onSubmit">
<h1>{{ t.title }}</h1>
<p>{{ t.lede }}</p>
<p v-if="t.disclaimer">{{ t.disclaimer }}</p>
<input type="hidden" name="access_key" :value="accessKey">
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden">
<input name="botcheck" tabindex="-1" autocomplete="off">
</div>
<section><h2>{{ t["section.visit"] }}</h2>
<label><span>{{ t["service"] }}</span><select name="service" required><option value="">—</option><option value="consultation">{{ t["service.consultation"] }}</option><option value="follow_up">{{ t["service.follow_up"] }}</option><option value="vaccination">{{ t["service.vaccination"] }}</option><option value="diagnostics">{{ t["service.diagnostics"] }}</option></select></label>
<label><span>{{ t["preferred_date"] }}</span><input name="preferred_date" type="date" required></label>
<label><span>{{ t["preferred_time"] }}</span><select name="preferred_time" required><option value="">—</option><option value="morning">{{ t["preferred_time.morning"] }}</option><option value="afternoon">{{ t["preferred_time.afternoon"] }}</option><option value="evening">{{ t["preferred_time.evening"] }}</option></select></label>
<label><span>{{ t["visit_for"] }}</span><select name="visit_for" required v-model="values.visit_for"><option value="">—</option><option value="self">{{ t["visit_for.self"] }}</option><option value="child">{{ t["visit_for.child"] }}</option></select></label>
<template v-if="values["visit_for"] === 'child'"><label><span>{{ t["child_name"] }}</span><input name="child_name" type="text" maxlength="80" autocomplete="name"></label></template></section>
<section><h2>{{ t["section.contact"] }}</h2>
<label><span>{{ t["name"] }}</span><input name="name" type="text" required maxlength="80" autocomplete="name"></label>
<label><span>{{ t["email"] }}</span><input name="email" type="email" maxlength="120" autocomplete="email"></label>
<label><span>{{ t["phone"] }}</span><input name="phone" type="tel" required maxlength="40" autocomplete="tel"></label></section>
<section><h2>{{ t["section.reason"] }}</h2>
<label><span>{{ t["reason"] }}</span><textarea name="reason" required maxlength="500"></textarea></label></section>
<section><h2>{{ t["section.consent"] }}</h2>
<label class="check"><input name="consent_contact" type="checkbox" value="yes" required><span>{{ t["consent_contact"] }}</span></label>
<label class="check"><input name="consent_privacy" type="checkbox" value="yes" required><span>{{ t["consent_privacy"] }}</span></label></section>
<!-- Turnstile hook: enable Turnstile on this form in Formgong, add the api.js script, and a div.cf-turnstile with data-sitekey="YOUR_TURNSTILE_SITE_KEY". -->
<button type="submit">{{ t.submit }}</button>
<p>{{ status }}</p>
</form>
</template>
<!-- Generated from src/content/industries.ts — npm run templates:write -->
<script>
let { lang = "en", accessKey = "fk_your_access_key" } = $props();
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 24576;
const LABELS = {
"uk": {
"title": "Форма запису до лікаря",
"lede": "Запис на візит до клініки. Форма питає час і коротку причину, не діагноз.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "Файл більший за 24 КБ. Додайте посилання.",
"disclaimer": "Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.",
"section.visit": "Візит",
"service": "Що потрібно?",
"service.consultation": "Консультація",
"service.follow_up": "Повторний візит",
"service.vaccination": "Щеплення",
"service.diagnostics": "Обстеження",
"preferred_date": "Бажана дата",
"preferred_time": "Бажаний час",
"preferred_time.morning": "Ранок",
"preferred_time.afternoon": "День",
"preferred_time.evening": "Вечір",
"visit_for": "Для кого візит?",
"visit_for.self": "Для мене",
"visit_for.child": "Для дитини",
"child_name": "Ім'я дитини",
"section.contact": "Контакт",
"name": "Ім'я",
"email": "Електронна пошта",
"phone": "Телефон",
"section.reason": "Причина",
"reason": "Коротка причина візиту",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Doctor appointment form",
"lede": "Book a clinic visit. The form asks for a time and a short reason, not a diagnosis.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "That file is over 24 KB. Paste a link instead.",
"disclaimer": "This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.",
"section.visit": "Visit",
"service": "What do you need?",
"service.consultation": "Consultation",
"service.follow_up": "Follow-up",
"service.vaccination": "Vaccination",
"service.diagnostics": "Tests",
"preferred_date": "Preferred date",
"preferred_time": "Preferred time",
"preferred_time.morning": "Morning",
"preferred_time.afternoon": "Afternoon",
"preferred_time.evening": "Evening",
"visit_for": "Who is the visit for?",
"visit_for.self": "Me",
"visit_for.child": "A child",
"child_name": "Child's name",
"section.contact": "Contact",
"name": "Name",
"email": "Email",
"phone": "Phone",
"section.reason": "Reason",
"reason": "Short reason for the visit",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz zapisu do lekarza",
"lede": "Zapis na wizytę. Formularz pyta o termin i krótki powód, nie o rozpoznanie.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Plik ma ponad 24 KB. Wklej link.",
"disclaimer": "Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.",
"section.visit": "Wizyta",
"service": "Czego dotyczy wizyta?",
"service.consultation": "Konsultacja",
"service.follow_up": "Wizyta kontrolna",
"service.vaccination": "Szczepienie",
"service.diagnostics": "Badania",
"preferred_date": "Preferowana data",
"preferred_time": "Preferowana pora",
"preferred_time.morning": "Rano",
"preferred_time.afternoon": "Popołudnie",
"preferred_time.evening": "Wieczór",
"visit_for": "Dla kogo jest wizyta?",
"visit_for.self": "Dla mnie",
"visit_for.child": "Dla dziecka",
"child_name": "Imię dziecka",
"section.contact": "Kontakt",
"name": "Imię",
"email": "E-mail",
"phone": "Telefon",
"section.reason": "Powód",
"reason": "Krótki powód wizyty",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Doktor randevu formu",
"lede": "Klinik ziyareti için randevu. Form saat ve kısa bir neden sorar, tanı değil.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "Dosya 24 KB'den büyük. Bağlantı ekleyin.",
"disclaimer": "Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.",
"section.visit": "Ziyaret",
"service": "Ne için geliyorsunuz?",
"service.consultation": "Muayene",
"service.follow_up": "Kontrol",
"service.vaccination": "Aşı",
"service.diagnostics": "Tetkik",
"preferred_date": "Tercih edilen tarih",
"preferred_time": "Tercih edilen saat",
"preferred_time.morning": "Sabah",
"preferred_time.afternoon": "Öğleden sonra",
"preferred_time.evening": "Akşam",
"visit_for": "Randevu kimin için?",
"visit_for.self": "Benim için",
"visit_for.child": "Çocuk için",
"child_name": "Çocuğun adı",
"section.contact": "İletişim",
"name": "Ad",
"email": "E-posta",
"phone": "Telefon",
"section.reason": "Neden",
"reason": "Ziyaretin kısa nedeni",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
let status = $state("");
let values = $state({ visit_for: "" });
const t = $derived(LABELS[lang] || LABELS.en);
function readFile(file) {
return new Promise((resolve, reject) => {
const reader = new FileReader();
reader.onload = () => {
const raw = String(reader.result || "");
const comma = raw.indexOf(",");
resolve(comma === -1 ? raw : raw.slice(comma + 1));
};
reader.onerror = () => reject(reader.error);
reader.readAsDataURL(file);
});
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = {};
const files = [];
for (const [key, value] of new FormData(form).entries()) {
if (value instanceof File) {
if (value.size) files.push([key, value]);
continue;
}
body[key] = String(value);
}
if (files.some((pair) => pair[1].size > FILE_MAX)) {
status = t.file_too_big;
return;
}
for (const [key, file] of files) {
body[key + "_filename"] = file.name;
body[key + "_data"] = await readFile(file);
}
const response = await fetch(ENDPOINT, {
method: "POST",
headers: { "Content-Type": "application/json", Accept: "application/json" },
body: JSON.stringify(body),
});
const result = await response.json();
status = result.success ? t.thanks : (result.message || "error");
}
</script>
<form onsubmit={onSubmit}>
<h1>{t.title}</h1>
<p>{t.lede}</p>
{#if t.disclaimer}<p>{t.disclaimer}</p>{/if}
<input type="hidden" name="access_key" value={accessKey}>
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden">
<input name="botcheck" tabindex="-1" autocomplete="off">
</div>
<section><h2>{t["section.visit"]}</h2>
<label><span>{t["service"]}</span><select name="service" required><option value="">—</option><option value="consultation">{t["service.consultation"]}</option><option value="follow_up">{t["service.follow_up"]}</option><option value="vaccination">{t["service.vaccination"]}</option><option value="diagnostics">{t["service.diagnostics"]}</option></select></label>
<label><span>{t["preferred_date"]}</span><input name="preferred_date" type="date" required></label>
<label><span>{t["preferred_time"]}</span><select name="preferred_time" required><option value="">—</option><option value="morning">{t["preferred_time.morning"]}</option><option value="afternoon">{t["preferred_time.afternoon"]}</option><option value="evening">{t["preferred_time.evening"]}</option></select></label>
<label><span>{t["visit_for"]}</span><select name="visit_for" required bind:value={values.visit_for}><option value="">—</option><option value="self">{t["visit_for.self"]}</option><option value="child">{t["visit_for.child"]}</option></select></label>
{#if values.visit_for === "child"}<label><span>{t["child_name"]}</span><input name="child_name" type="text" maxlength="80"></label>{/if}</section>
<section><h2>{t["section.contact"]}</h2>
<label><span>{t["name"]}</span><input name="name" type="text" required maxlength="80"></label>
<label><span>{t["email"]}</span><input name="email" type="email" maxlength="120"></label>
<label><span>{t["phone"]}</span><input name="phone" type="tel" required maxlength="40"></label></section>
<section><h2>{t["section.reason"]}</h2>
<label><span>{t["reason"]}</span><textarea name="reason" required maxlength="500"></textarea></label></section>
<section><h2>{t["section.consent"]}</h2>
<label class="check"><input name="consent_contact" type="checkbox" value="yes" required><span>{t["consent_contact"]}</span></label>
<label class="check"><input name="consent_privacy" type="checkbox" value="yes" required><span>{t["consent_privacy"]}</span></label></section>
<!-- Turnstile hook: enable Turnstile on this form in Formgong, add the api.js script, and a div.cf-turnstile with data-sitekey="YOUR_TURNSTILE_SITE_KEY". -->
<button type="submit">{t.submit}</button>
<p>{status}</p>
</form>