[et_pb_section bb_built=“1” admin_label=“section”][et_pb_row admin_label=“Zeile” background_position=“top_left” background_repeat=“repeat” background_size=“initial” _builder_version=“3.0.51”][et_pb_column type=“4_4”][et_pb_contact_form admin_label=“Kontaktformular” _builder_version=“3.0.51” title=“Registrierung Fach­han­del” success_message=“Vielen Dank für Ihre Anmel­dung im Fach­han­del­be­reich. Wir prü­fen Ihre Ein­ga­ben und mel­den uns umge­hend bei Ihnen.” email=“” captcha=“on” use_redirect=“off” input_border_radius=“0” border_style=“solid” custom_button=“on” button_letter_spacing=“0” button_icon_placement=“right” button_letter_spacing_hover=“0” submit_button_text=“Registrieren” button_icon=”%%202%%”] [et_pb_contact_field field_title=“Vorname” field_type=“input” field_id=“Name_2” required_mark=“on” fullwidth_field=“off” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“all” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22email%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_title=“Nachname” field_type=“input” field_id=“Name” required_mark=“on” fullwidth_field=“off” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“all” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22email%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_id=“Street” field_title=“Strasse” field_type=“input” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“all” required_mark=“on” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” fullwidth_field=“on” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_id=“Nummer” field_title=“Hausnummer” field_type=“input” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“all” required_mark=“on” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” fullwidth_field=“off” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_id=“ZIP_Code” field_title=“PLZ” field_type=“input” checkbox_checked=“off” min_length=“0” max_length=“5” allowed_symbols=“numbers” required_mark=“on” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” fullwidth_field=“off” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_id=“City” field_title=“Ort” field_type=“input” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“letters” required_mark=“on” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” fullwidth_field=“off” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_id=“Country” field_title=“Land” field_type=“input” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“letters” required_mark=“on” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” fullwidth_field=“off” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_title=“Ihre E‑Mail-Adres­se” field_type=“email” field_id=“Email” required_mark=“on” fullwidth_field=“off” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“all” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_id=“Group” field_title=“Berufsgruppe” field_type=“radio” checkbox_checked=“off” radio_options=“%91{%22value%22:%22Arzt%22,%22checked%22:0},{%22value%22:%22Therapeut%22,%22checked%22:0},{%22value%22:%22Heilpraktiker%22,%22checked%22:0},{%22value%22:%22Apotheker%22,%22checked%22:0},{%22value%22:%22sonstiges%22,%22checked%22:0}%93” min_length=“0” max_length=“0” allowed_symbols=“all” required_mark=“on” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” fullwidth_field=“off” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /][et_pb_contact_field field_id=“Field_8” field_title=“Anmerkungen” field_type=“text” checkbox_checked=“off” min_length=“0” max_length=“0” allowed_symbols=“all” required_mark=“off” conditional_logic=“off” conditional_logic_relation=“off” conditional_logic_rules=“%91{%22field%22:%22name%22,%22condition%22:%22is%22,%22value%22:%22%22}%93” fullwidth_field=“on” form_field_font_select=“default” form_field_font=”||||” use_border_color=“off” border_style=“solid” /] [/et_pb_contact_form][/et_pb_column][/et_pb_row][/et_pb_section]