<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
    <meta name="referrer" content="no-referrer-when-downgrade">
    
    
            

    <link href="https://postnl.tfaforms.net/dist/form-builder/5.0.0/wforms-layout.css?v=02c56e273d0dffbee8431cda4b61b3f646e19fd2" rel="stylesheet" type="text/css" />

    <link href="https://postnl.tfaforms.net/uploads/themes/theme-64.css" rel="stylesheet" type="text/css" />
    <link href="https://postnl.tfaforms.net/dist/form-builder/5.0.0/wforms-jsonly.css?v=02c56e273d0dffbee8431cda4b61b3f646e19fd2" rel="alternate stylesheet" title="This stylesheet activated by javascript" type="text/css" />
    
    
    


<div class="wFormContainer" >
    <div class="wFormHeader"></div>
    <style type="text/css">
                #tfa_31-L,
                label[id^="tfa_31["] {
                    width: 331px !important;
                    min-width: 0px;
                }
            
                #tfa_44,
                *[id^="tfa_44["] {
                    width: 400px !important;
                }
                #tfa_44-D,
                *[id^="tfa_44["][class~="field-container-D"] {
                    width: auto !important;
                }
            
                #tfa_59,
                *[id^="tfa_59["] {
                    width: 400px !important;
                }
                #tfa_59-D,
                *[id^="tfa_59["][class~="field-container-D"] {
                    width: auto !important;
                }
            
                #tfa_72,
                *[id^="tfa_72["] {
                    width: 400px !important;
                }
                #tfa_72-D,
                *[id^="tfa_72["][class~="field-container-D"] {
                    width: auto !important;
                }
            
                #tfa_44,
                *[id^="tfa_44["] {
                    height: 200px !important
                }
                #tfa_44-D,
                *[id^="tfa_44["][class~="field-container-D"] {
                    height: auto !important;
                }
                #tfa_44-L,
                label[id^="tfa_44["],
                *[id^="tfa_44["][id$="-L"] {
                    height: auto !important;
                }
            
                #tfa_59,
                *[id^="tfa_59["] {
                    height: 130px !important
                }
                #tfa_59-D,
                *[id^="tfa_59["][class~="field-container-D"] {
                    height: auto !important;
                }
                #tfa_59-L,
                label[id^="tfa_59["],
                *[id^="tfa_59["][id$="-L"] {
                    height: auto !important;
                }
            
                #tfa_72,
                *[id^="tfa_72["] {
                    height:  !important
                }
                #tfa_72-D,
                *[id^="tfa_72["][class~="field-container-D"] {
                    height: auto !important;
                }
                #tfa_72-L,
                label[id^="tfa_72["],
                *[id^="tfa_72["][id$="-L"] {
                    height: auto !important;
                }
            </style><div class=""><div class="wForm" id="4960105-WRPR" data-language="fr" dir="ltr">
<div class="codesection" id="code-4960105"></div>
<form method="post" action="https://postnl.tfaforms.net/api_v2/rest/workflow/processor" class="hintsBelow labelsAbove" id="4960105">
<div class="oneField field-container-D   hintsBelow " id="tfa_31-D">
<label id="tfa_31-L" class="label preField " for="tfa_31">Sujet</label><br><div class="inputWrapper"><select id="tfa_31" name="tfa_31" title="Sujet" class=""><option value="">Veuillez sélectionner</option>
<option value="tfa_75" id="tfa_75" class="">Citation requise</option>
<option value="tfa_76" id="tfa_76" class="">Question/commentaire</option></select></div>
</div>
<div class="oneField field-container-D    " id="tfa_26-D">
<label id="tfa_26-L" class="label preField reqMark" for="tfa_26">Prénom</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_26" name="tfa_26" value="" autocomplete="off" title="Prénom" class="validate-alphanum required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_66-D">
<label id="tfa_66-L" class="label preField reqMark" for="tfa_66">Nom</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_66" name="tfa_66" value="" autocomplete="off" title="Nom" class="validate-alphanum required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_61-D">
<label id="tfa_61-L" class="label preField " for="tfa_61">Nom de la société</label><br><div class="inputWrapper"><input type="text" id="tfa_61" name="tfa_61" value="" autocomplete="off" title="Nom de la société" class="validate-alphanum"></div>
</div>
<div class="oneField field-container-D   hintsBelow " id="tfa_19-D">
<label id="tfa_19-L" class="label preField reqMark" for="tfa_19">Numéro de téléphone</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_19" name="tfa_19" value="" autocomplete="off" title="Numéro de téléphone" class="validate-integer required"></div>
</div>
<div class="oneField field-container-D    " id="tfa_12-D">
<label id="tfa_12-L" class="label preField reqMark" for="tfa_12">Adresse e-mail</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_12" name="tfa_12" value="" autocomplete="off" title="Adresse e-mail" class="validate-email required"></div>
</div>
<div class="oneField field-container-D   hintsBelow " id="tfa_44-D">
<label id="tfa_44-L" class="label preField " for="tfa_44">Ma question</label><br><div class="inputWrapper"><textarea maxlength="255" id="tfa_44" name="tfa_44" title="Ma question" class=""></textarea></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_49-D">
<label id="tfa_49-L" class="label preField reqMark" for="tfa_49">Taal</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_49" name="tfa_49" value="fr_BE" default="fr_BE" maxlength="50" title="Taal" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_59-D">
<label id="tfa_59-L" class="label preField " for="tfa_59">E-mail tekst</label><br><div class="inputWrapper"><textarea maxlength="300" id="tfa_59" name="tfa_59" title="E-mail tekst" class=""></textarea></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_51-D">
<label id="tfa_51-L" class="label preField reqMark" for="tfa_51">Categorie</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_51" name="tfa_51" value="Contact opnemen" default="Contact opnemen" maxlength="50" title="Categorie" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_53-D">
<label id="tfa_53-L" class="label preField reqMark" for="tfa_53">Webform Source</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_53" name="tfa_53" value="pharma contact be" default="pharma contact be" title="Webform Source" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_68-D">
<label id="tfa_68-L" class="label preField reqMark" for="tfa_68">Record Type ID</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_68" name="tfa_68" value="0120J000000opbSQAQ" default="0120J000000opbSQAQ" title="Record Type ID" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_70-D">
<label id="tfa_70-L" class="label preField reqMark" for="tfa_70">Formulier_titel</label><br><div class="inputWrapper"><input aria-required="true" type="text" id="tfa_70" name="tfa_70" value="Colis pharmaceutique" default="Colis pharmaceutique" title="Formulier_titel" class="required"></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_78-D">
<label id="tfa_78-L" class="label preField " for="tfa_78">Campagne code</label><br><div class="inputWrapper"><input type="text" id="tfa_78" name="tfa_78" value="701w0000000oeceAAA" default="701w0000000oeceAAA" title="Campagne code" class=""></div>
</div>
<div class="oneField field-container-D     wf-acl-hidden" id="tfa_72-D">
<label id="tfa_72-L" class="label preField " for="tfa_72">Subjectline bevestigingsmail (bij leeg veld wordt default Marketing Cloud waarde gebruikt)</label><br><div class="inputWrapper"><textarea maxlength="300" id="tfa_72" name="tfa_72" title="Subjectline bevestigingsmail (bij leeg veld wordt default Marketing Cloud waarde gebruikt)" class=""></textarea></div>
</div>
<div class="actions" id="4960105-A" data-contentid="submit_button"><input type="submit" data-label="Envoyer" class="primaryAction" id="submit_button" value="Envoyer"></div>
<div style="clear:both"></div>
<input type="hidden" value="45-5502e22a35cd95227fafa9879bbbd532" name="tfa_dbCounters" id="tfa_dbCounters" autocomplete="off"><input type="hidden" value="4960105" name="tfa_dbFormId" id="tfa_dbFormId"><input type="hidden" value="" name="tfa_dbResponseId" id="tfa_dbResponseId"><input type="hidden" value="45dcb41bfac88efa25d21bffc2c931d7" name="tfa_dbControl" id="tfa_dbControl"><input type="hidden" value="" name="tfa_dbWorkflowSessionUuid" id="tfa_dbWorkflowSessionUuid"><input type="hidden" value="1731961954" name="tfa_dbTimeStarted" id="tfa_dbTimeStarted" autocomplete="off"><input type="hidden" value="7" name="tfa_dbVersionId" id="tfa_dbVersionId"><input type="hidden" value="" name="tfa_switchedoff" id="tfa_switchedoff">
</form>
</div></div><div class="wFormFooter"><p class="supportInfo"><br></p></div>
  <p class="supportInfo" >
      </p>
 </div>

Farmaceutisch pakket                                                                                

Contactez-nous

PostNL Pharma & Care

be - fr - déclaration de confidentialité de postnl

be - fr - tout sur les cookies

Conditions d’utilisation

Conditions Générales

be -envoyer - service d'expedition en ligne

Aller á

be fr - service & contact

Voir aussi

PostNL Pharma & Care

Envoyer

Réceptoin

Solutions professionnelles

Á propos de PostNL

Aller á

PostNL-app

Voir aussi