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HTML-Format |
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<form class="aui" method="POST" action="mailto:support@kv.digital?subject=Portalregistrierung" enctype="text/plain" accept-charset="UTF-8">
<div class="field-group">
<label for="comment-email">E-Mail-Adresse
<span class="aui-icon icon-required">(required)</span></label>
<input class="text medium-long-field" type="text"
id="comment-email" name="Email" placeholder="IhrVorname.IhrNachname@IhreOrganisation.de" data-aui-validation-field required="required" minlength="1" pattern=".+@+..*\...*">
<div class="description">Ihre geschäftliche E-Mail-Adresse. Private E-Mail-Adressen oder E-Mail-Adressen ohne persönlichen Mandanten, bspw. Info-Adressen, sind nicht erlaubt.</div>
</div>
<div class="field-group">
<label for="text-input">Vorname<span class="aui-icon icon-required">required</span></label>
<input class="text medium-long-field" type="text" id="text-input" name="Vorname" title="Text input" data-aui-validation-field required="required" minlength="1">
<div class="description">Vorname (für Erstellung des Benutzernamens)</div>
</div>
<div class="field-group">
<label for="text-input">Nachname<span class="aui-icon icon-required">required</span></label>
<input class="text medium-long-field" type="text" id="text-input" name="Nachname" title="Text input" data-aui-validation-field required="required" minlength="1">
<div class="description">Nachname (für Erstellung des Benutzernamens)</div>
</div>
<div class="field-group">
<label for="text-input">Unternehmen<span class="aui-icon icon-required">required</span></label>
<input class="text medium-long-field" type="text" id="text-input" name="Unternehmen" title="Text input" data-aui-validation-field required="required" minlength="1">
<div class="description">Unternehmen oder Organisation, für welche(s) Sie arbeiten</div>
</div>
<div class="field-group">
<label for="select-example">Art der Organisation<span class="aui-icon icon-required">required</span></label>
<select class="select" id="select-example" name="Organisationsart">
<option value="SWH">Softwarehersteller</option>
<option value="VSP">Service- und Vertriebs-Dienstleister</option>
<option value="KV">Kassenärztliche Vereinigung</option>
<option value="KBV">Kassenärztliche Bundesvereinigung</option>
<option value="KH">Krankenhaus</option>
<option value="Lab">Labor</option>
<option value="Verband">Verband</option>
</select>
<div class="description">Bitte wählen Sie die Art Ihrer Organisation aus.</div>
</div>
<div class="field-group">
<label for="comment-input">Begründung<span class="aui-icon icon-required">required</span></label>
<textarea class="textarea medium-long-field" name="Begruendung"
id="comment-input" placeholder="Kurze Erklärung, wofür Sie den Zugang zum Partnerportal verwenden möchten" data-aui-validation-field required="required" minlength="1"></textarea>
</div>
<div class="buttons-container">
<div class="buttons">
<input class="button submit" type="submit" value="Senden" id="comment-save-button">
<a class="cancel" href="#">Abbrechen</a>
</div>
</div>
</form>
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