{"id":144370,"date":"2022-01-14T15:38:12","date_gmt":"2022-01-14T14:38:12","guid":{"rendered":"https:\/\/vetinparis.com\/?page_id=144370"},"modified":"2022-01-21T09:58:30","modified_gmt":"2022-01-21T08:58:30","slug":"demande-de-prise-en-charge","status":"publish","type":"page","link":"https:\/\/cms.vetinparis.com\/en\/demande-de-prise-en-charge\/","title":{"rendered":"Demande de prise en charge"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row css=&#8221;.vc_custom_1642755462108{background-color: #eeeeee !important;border-radius: 25px !important;}&#8221;][vc_column][vc_column_text]<\/p>\n<p style=\"text-align: center;\"><span style=\"color: #000000;\">Pour toute demande de prise en charge, vous pouvez remplir le formulaire ci-dessous ou bien imprimer la version PDF.<br \/>\n<\/span><\/p>\n<p>[\/vc_column_text]<style type=\"text\/css\" data-type=\"the7_shortcodes-inline-css\">#default-btn-d4d3efb827a11c81a6196513d0a0d0ba.ico-right-side > i {\n  margin-right: 0px;\n  margin-left: 8px;\n}\n#default-btn-d4d3efb827a11c81a6196513d0a0d0ba > i {\n  margin-right: 8px;\n}\n<\/style><div class=\"btn-align-center\"><a href=\"https:\/\/boutique.vetinparis.com\/wp-content\/uploads\/2022\/01\/demande-de-prise-en-charge.pdf\" class=\"default-btn-shortcode dt-btn dt-btn-m link-hover-off  vc_custom_1642607327630\" target=\"_blank\" id=\"default-btn-d4d3efb827a11c81a6196513d0a0d0ba\" rel=\"noopener\"><i class=\"fas fa-file-download\"><\/i><span>T\u00c9L\u00c9CHARGER LE PDF<\/span><\/a><\/div>[\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1642606277650{margin-bottom: 35px !important;}&#8221;][vc_column][vc_column_text]<form class=\"af-form acf-form\" method=\"POST\" action=\"https:\/\/cms.vetinparis.com\/en\/wp-json\/wp\/v2\/pages\/144370\" id=\"form_61e1893dac557\" data-key=\"form_61e1893dac557\"><div class=\"af-fields acf-fields acf-form-fields -top\">\t<div id=\"acf-form-data\" class=\"acf-hidden\">\n\t\t<input type=\"hidden\" id=\"_acf_screen\" name=\"_acf_screen\" value=\"acf_form\"\/><input type=\"hidden\" id=\"_acf_post_id\" name=\"_acf_post_id\" value=\"0\"\/><input type=\"hidden\" id=\"_acf_validation\" name=\"_acf_validation\" value=\"1\"\/><input type=\"hidden\" id=\"_acf_form\" name=\"_acf_form\" value=\"0\"\/><input type=\"hidden\" id=\"_acf_nonce\" name=\"_acf_nonce\" value=\"9badbc9d16\"\/><input type=\"hidden\" id=\"_acf_changed\" name=\"_acf_changed\" value=\"0\"\/>\t<\/div>\n\t<div class=\"acf-hidden\"><input type=\"hidden\" name=\"_acfnonce\" value=\"550015d6ba\"><input type=\"hidden\" name=\"nonce\" value=\"550015d6ba\"><input type=\"hidden\" name=\"af_form\" value=\"form_61e1893dac557\"><input type=\"hidden\" name=\"af_form_args\" value=\"eyJhamF4IjpmYWxzZSwiZGlzcGxheV90aXRsZSI6ZmFsc2UsImRpc3BsYXlfZGVzY3JpcHRpb24iOmZhbHNlLCJpZCI6ImZvcm1fNjFlMTg5M2RhYzU1NyIsInZhbHVlcyI6W10sInN1Ym1pdF90ZXh0IjoiU3VibWl0IiwicmVkaXJlY3QiOm51bGwsInRhcmdldCI6Imh0dHBzOlwvXC9jbXMudmV0aW5wYXJpcy5jb21cL2VuXC93cC1qc29uXC93cFwvdjJcL3BhZ2VzXC8xNDQzNzAiLCJlY2hvIjp0cnVlLCJleGNsdWRlX2ZpZWxkcyI6W10sInVwbG9hZGVyIjoid3AiLCJmaWx0ZXJfbW9kZSI6ZmFsc2UsImxhYmVsX3BsYWNlbWVudCI6InRvcCIsImluc3RydWN0aW9uX3BsYWNlbWVudCI6ImxhYmVsIiwiaG9uZXlwb3QiOnRydWV9\"><input type=\"hidden\" name=\"_acf_form\" value=\"eyJhamF4IjpmYWxzZSwiZGlzcGxheV90aXRsZSI6ZmFsc2UsImRpc3BsYXlfZGVzY3JpcHRpb24iOmZhbHNlLCJpZCI6ImZvcm1fNjFlMTg5M2RhYzU1NyIsInZhbHVlcyI6W10sInN1Ym1pdF90ZXh0IjoiU3VibWl0IiwicmVkaXJlY3QiOm51bGwsInRhcmdldCI6Imh0dHBzOlwvXC9jbXMudmV0aW5wYXJpcy5jb21cL2VuXC93cC1qc29uXC93cFwvdjJcL3BhZ2VzXC8xNDQzNzAiLCJlY2hvIjp0cnVlLCJleGNsdWRlX2ZpZWxkcyI6W10sInVwbG9hZGVyIjoid3AiLCJmaWx0ZXJfbW9kZSI6ZmFsc2UsImxhYmVsX3BsYWNlbWVudCI6InRvcCIsImluc3RydWN0aW9uX3BsYWNlbWVudCI6ImxhYmVsIiwiaG9uZXlwb3QiOnRydWV9\"><input type=\"hidden\" name=\"af_form_nonce\" value=\"4548793966\"><label for=\"af_email_for_non_humans_form_61e1893dac557\" aria-hidden=\"true\">Email for non-humans<\/label><input type=\"text\" name=\"email_for_non_humans\" id=\"af_email_for_non_humans_form_61e1893dac557\" tabindex=\"-1\" autocomplete=\"off\" \/><input type=\"hidden\" name=\"af_origin_url\" value=\"https:\/\/cms.vetinparis.com\/en\/wp-json\/wp\/v2\/pages\/144370\" \/><\/div><div class=\"af-field af-field-type-page af-field- acf-field acf-field-page acf-field-61e817e19e0c7\" data-name=\"\" data-key=\"field_61e817e19e0c7\" data-type=\"page\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e817e19e0c7\">V\u00e9t\u00e9rinaire prescripteur<\/label><\/div><div class=\"af-input acf-input\">    <a href=\"\" class=\"af-page-button\" data-key=\"field_61e817e19e0c7\" data-show-numbering=\"true\">\n      <span class=\"title\">V\u00e9t\u00e9rinaire prescripteur<\/span>\n    <\/a>\n\n    <button class=\"af-previous-button\">Pr\u00e9c\u00e9dent<\/button>\n    <button class=\"af-next-button\">Suivant<\/button>\n    <\/div><\/div><div class=\"af-field af-field-type-message af-field- acf-field acf-field-message acf-field-61e817fb9e0c8\" data-name=\"\" data-key=\"field_61e817fb9e0c8\" data-type=\"message\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e817fb9e0c8\"><\/label><\/div><div class=\"af-input acf-input\"><h3>V\u00e9t\u00e9rinaire prescripteur<\/h3>\n<\/div><\/div><div class=\"af-field af-field-type-text af-field-nom-veterinaire acf-field acf-field-text acf-field-61e818109e0c9 af-field-required\" data-name=\"nom_veterinaire\" data-key=\"field_61e818109e0c9\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e818109e0c9\">Nom <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e818109e0c9\" name=\"acf[field_61e818109e0c9]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-adresse-veterinaire acf-field acf-field-text acf-field-61e818279e0ca\" data-name=\"adresse_veterinaire\" data-key=\"field_61e818279e0ca\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e818279e0ca\">Adresse<\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e818279e0ca\" name=\"acf[field_61e818279e0ca]\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-telephone-email-veterinaire acf-field acf-field-text acf-field-61e818329e0cb af-field-required\" data-name=\"telephone_email_veterinaire\" data-key=\"field_61e818329e0cb\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e818329e0cb\">T\u00e9l\u00e9phone ou adresse email <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e818329e0cb\" name=\"acf[field_61e818329e0cb]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-page af-field- acf-field acf-field-page acf-field-61e189dbadb09\" data-name=\"\" data-key=\"field_61e189dbadb09\" data-type=\"page\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e189dbadb09\">Propri\u00e9taire<\/label><\/div><div class=\"af-input acf-input\">    <a href=\"\" class=\"af-page-button\" data-key=\"field_61e189dbadb09\" data-show-numbering=\"true\">\n      <span class=\"title\">Propri\u00e9taire<\/span>\n    <\/a>\n\n    <button class=\"af-previous-button\">Pr\u00e9c\u00e9dent<\/button>\n    <button class=\"af-next-button\">Suivant<\/button>\n    <\/div><\/div><div class=\"af-field af-field-type-message af-field- acf-field acf-field-message acf-field-61e18cf145617\" data-name=\"\" data-key=\"field_61e18cf145617\" data-type=\"message\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18cf145617\"><\/label><\/div><div class=\"af-input acf-input\"><h3>Propri\u00e9taire<\/h3>\n<\/div><\/div><div class=\"af-field af-field-type-text af-field-nom-proprietaire acf-field acf-field-text acf-field-61e18a2badb0a af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"nom_proprietaire\" data-key=\"field_61e18a2badb0a\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18a2badb0a\">Nom <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18a2badb0a\" name=\"acf[field_61e18a2badb0a]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-prenom-proprietaire acf-field acf-field-text acf-field-61e18a66adb0b af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"prenom_proprietaire\" data-key=\"field_61e18a66adb0b\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18a66adb0b\">Pr\u00e9nom <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18a66adb0b\" name=\"acf[field_61e18a66adb0b]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-adresse-proprietaire acf-field acf-field-text acf-field-61e18a7dadb0c\" data-name=\"adresse_proprietaire\" data-key=\"field_61e18a7dadb0c\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18a7dadb0c\">Adresse<\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18a7dadb0c\" name=\"acf[field_61e18a7dadb0c]\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-telephone-proprietaire acf-field acf-field-text acf-field-61e18a87adb0d af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"telephone_proprietaire\" data-key=\"field_61e18a87adb0d\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18a87adb0d\">T\u00e9l\u00e9phone <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18a87adb0d\" name=\"acf[field_61e18a87adb0d]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-email af-field-email-proprietaire acf-field acf-field-email acf-field-61e18a8fadb0e af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"email_proprietaire\" data-key=\"field_61e18a8fadb0e\" data-type=\"email\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18a8fadb0e\">Adresse email <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"email\" id=\"acf-field_61e18a8fadb0e\" name=\"acf[field_61e18a8fadb0e]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-page af-field- acf-field acf-field-page acf-field-61e18c000bf5d\" data-name=\"\" data-key=\"field_61e18c000bf5d\" data-type=\"page\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c000bf5d\">Animal<\/label><\/div><div class=\"af-input acf-input\">    <a href=\"\" class=\"af-page-button\" data-key=\"field_61e18c000bf5d\" data-show-numbering=\"true\">\n      <span class=\"title\">Animal<\/span>\n    <\/a>\n\n    <button class=\"af-previous-button\">Suivant<\/button>\n    <button class=\"af-next-button\">Pr\u00e9c\u00e9dent<\/button>\n    <\/div><\/div><div class=\"af-field af-field-type-message af-field- acf-field acf-field-message acf-field-61e18cfe45618\" data-name=\"\" data-key=\"field_61e18cfe45618\" data-type=\"message\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18cfe45618\"><\/label><\/div><div class=\"af-input acf-input\"><h3>Animal<\/h3>\n<\/div><\/div><div class=\"af-field af-field-type-text af-field-nom-animal acf-field acf-field-text acf-field-61e18c0e0bf5e af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"nom_animal\" data-key=\"field_61e18c0e0bf5e\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c0e0bf5e\">Nom <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18c0e0bf5e\" name=\"acf[field_61e18c0e0bf5e]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-date-picker af-field-naissance-animal acf-field acf-field-date-picker acf-field-61e18c1c0bf5f af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"naissance_animal\" data-key=\"field_61e18c1c0bf5f\" data-type=\"date_picker\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c1c0bf5f\">Date de naissance <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\">\t\t<div class=\"acf-date-picker acf-input-wrap\" data-date_format=\"dd\/mm\/yy\" data-first_day=\"1\">\n\t\t\t<input type=\"hidden\" id=\"acf-field_61e18c1c0bf5f\" name=\"acf[field_61e18c1c0bf5f]\" value=\"\"\/>\t\t\t<input type=\"text\" class=\"input\" value=\"\" data-default-to-today=\"0\"\/>\t\t<\/div>\n\t\t\t<\/div><\/div><div class=\"af-field af-field-type-radio af-field-sexe-animal acf-field acf-field-radio acf-field-61e18c400bf60 af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"sexe_animal\" data-key=\"field_61e18c400bf60\" data-type=\"radio\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c400bf60\">Sexe <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><input type=\"hidden\" name=\"acf[field_61e18c400bf60]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_61e18c400bf60-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_61e18c400bf60-femelle\" name=\"acf[field_61e18c400bf60]\" value=\"Femelle\" checked=\"checked\"\/>Femelle<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_61e18c400bf60-male\" name=\"acf[field_61e18c400bf60]\" value=\"M\u00e2le\"\/>M\u00e2le<\/label><\/li><\/ul><\/div><\/div><div class=\"af-field af-field-type-radio af-field-sterilise-animal acf-field acf-field-radio acf-field-61e18c5c0bf61 af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"sterilise_animal\" data-key=\"field_61e18c5c0bf61\" data-type=\"radio\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c5c0bf61\">St\u00e9rilis\u00e9 <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><input type=\"hidden\" name=\"acf[field_61e18c5c0bf61]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_61e18c5c0bf61-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_61e18c5c0bf61-oui\" name=\"acf[field_61e18c5c0bf61]\" value=\"Oui\" checked=\"checked\"\/>Oui<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_61e18c5c0bf61-non\" name=\"acf[field_61e18c5c0bf61]\" value=\"Non\"\/>Non<\/label><\/li><\/ul><\/div><\/div><div class=\"af-field af-field-type-text af-field-espece-animal acf-field acf-field-text acf-field-61e18c6c0bf62 af-field-required\" data-width=\"50\" style=\"width: 50%;\" data-name=\"espece_animal\" data-key=\"field_61e18c6c0bf62\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c6c0bf62\">Esp\u00e8ce <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18c6c0bf62\" name=\"acf[field_61e18c6c0bf62]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-race-animal acf-field acf-field-text acf-field-61e18c770bf63\" data-width=\"50\" style=\"width: 50%;\" data-name=\"race_animal\" data-key=\"field_61e18c770bf63\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c770bf63\">Race<\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18c770bf63\" name=\"acf[field_61e18c770bf63]\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-couleur-animal acf-field acf-field-text acf-field-61e81feb1bbd2 af-field-required\" data-name=\"couleur_animal\" data-key=\"field_61e81feb1bbd2\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e81feb1bbd2\">Couleur <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e81feb1bbd2\" name=\"acf[field_61e81feb1bbd2]\" required=\"required\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-puce-animal acf-field acf-field-text acf-field-61e18c7e0bf64\" data-width=\"50\" style=\"width: 50%;\" data-name=\"puce_animal\" data-key=\"field_61e18c7e0bf64\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c7e0bf64\">Num\u00e9ro de puce \u00e9lectronique<\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18c7e0bf64\" name=\"acf[field_61e18c7e0bf64]\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-text af-field-tatouage-animal acf-field acf-field-text acf-field-61e18c8b0bf65\" data-width=\"50\" style=\"width: 50%;\" data-name=\"tatouage_animal\" data-key=\"field_61e18c8b0bf65\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e18c8b0bf65\">Tatouage<\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e18c8b0bf65\" name=\"acf[field_61e18c8b0bf65]\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-page af-field- acf-field acf-field-page acf-field-61e53785c5a80\" data-name=\"\" data-key=\"field_61e53785c5a80\" data-type=\"page\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e53785c5a80\">Vous souhaitez<\/label><\/div><div class=\"af-input acf-input\">    <a href=\"\" class=\"af-page-button\" data-key=\"field_61e53785c5a80\" data-show-numbering=\"true\">\n      <span class=\"title\">Vous souhaitez<\/span>\n    <\/a>\n\n    <button class=\"af-previous-button\">Suivant<\/button>\n    <button class=\"af-next-button\">Pr\u00e9c\u00e9dent<\/button>\n    <\/div><\/div><div class=\"af-field af-field-type-message af-field- acf-field acf-field-message acf-field-61e591d9c5c10\" data-name=\"\" data-key=\"field_61e591d9c5c10\" data-type=\"message\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e591d9c5c10\"><\/label><\/div><div class=\"af-input acf-input\"><h3>Vous souhaitez<\/h3>\n<\/div><\/div><div class=\"af-field af-field-type-checkbox af-field-souhait acf-field acf-field-checkbox acf-field-61e537a3c5a82 af-field-required\" data-name=\"souhait\" data-key=\"field_61e537a3c5a82\" data-type=\"checkbox\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e537a3c5a82\">Vous souhaitez : <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><input type=\"hidden\" name=\"acf[field_61e537a3c5a82]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_61e537a3c5a82-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_61e537a3c5a82-Une-prise-en-charge-globale\" name=\"acf[field_61e537a3c5a82][]\" value=\"Une prise en charge globale\"\/> Une prise en charge globale<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_61e537a3c5a82-Une-hospitalisation-(jour\/nuit\/week-end)\" name=\"acf[field_61e537a3c5a82][]\" value=\"Une hospitalisation (jour\/nuit\/week-end)\"\/> Une hospitalisation (jour\/nuit\/week-end)<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_61e537a3c5a82-Autre\" name=\"acf[field_61e537a3c5a82][]\" value=\"Autre\"\/> Autre<\/label><\/li>\n<\/ul>\n<\/div><\/div><div class=\"title-blue af-field af-field-type-message af-field- acf-field acf-field-message acf-field-61e8344707e18\" data-name=\"\" data-key=\"field_61e8344707e18\" data-type=\"message\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e8344707e18\"><\/label><\/div><div class=\"af-input acf-input\"><h3>Examen Compl\u00e9mentaire<\/h3>\n<\/div><\/div><div class=\"af-field af-field-type-checkbox af-field-examen-complementaire acf-field acf-field-checkbox acf-field-61e5380fc5a83 af-field-required\" data-name=\"examen_complementaire\" data-key=\"field_61e5380fc5a83\" data-type=\"checkbox\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e5380fc5a83\">Examen compl\u00e9mentaire <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><input type=\"hidden\" name=\"acf[field_61e5380fc5a83]\"\/><ul class=\"acf-checkbox-list acf-bl\" role=\"group\" aria-labelledby=\"acf-field_61e5380fc5a83-label\">\n<li><label><input type=\"checkbox\" id=\"acf-field_61e5380fc5a83-Radiographie\" name=\"acf[field_61e5380fc5a83][]\" value=\"Radiographie\"\/> Radiographie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_61e5380fc5a83-Echographie\" name=\"acf[field_61e5380fc5a83][]\" value=\"Echographie\"\/> Echographie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_61e5380fc5a83-Endoscopie-\/-Fibroscopie\" name=\"acf[field_61e5380fc5a83][]\" value=\"Endoscopie \/ Fibroscopie\"\/> Endoscopie \/ Fibroscopie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_61e5380fc5a83-Scanner\" name=\"acf[field_61e5380fc5a83][]\" value=\"Scanner\"\/> Scanner<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_61e5380fc5a83-Chirurgie\" name=\"acf[field_61e5380fc5a83][]\" value=\"Chirurgie\"\/> Chirurgie<\/label><\/li>\n<li><label><input type=\"checkbox\" id=\"acf-field_61e5380fc5a83-Analyses\" name=\"acf[field_61e5380fc5a83][]\" value=\"Analyses\"\/> Analyses<\/label><\/li>\n<\/ul>\n<\/div><\/div><div class=\"af-field af-field-type-text af-field-region acf-field acf-field-text acf-field-61e53840c5a84\" data-name=\"region\" data-key=\"field_61e53840c5a84\" data-type=\"text\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e53840c5a84\">R\u00e9gion<\/label><\/div><div class=\"af-input acf-input\"><div class=\"acf-input-wrap\"><input type=\"text\" id=\"acf-field_61e53840c5a84\" name=\"acf[field_61e53840c5a84]\"\/><\/div><\/div><\/div><div class=\"af-field af-field-type-radio af-field-prelevements-si-necessaire acf-field acf-field-radio acf-field-61e53845c5a85 af-field-required\" data-name=\"prelevements_si_necessaire\" data-key=\"field_61e53845c5a85\" data-type=\"radio\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e53845c5a85\">Pr\u00e9l\u00e8vements si n\u00e9c\u00e9ssaire <span class=\"acf-required\">*<\/span><\/label><p class=\"af-field-instructions -placement-label\">(Ponctions, Biopsies, ...)<\/p><\/div><div class=\"af-input acf-input\"><input type=\"hidden\" name=\"acf[field_61e53845c5a85]\"\/><ul class=\"acf-radio-list acf-bl\" data-allow_null=\"0\" data-other_choice=\"0\" role=\"radiogroup\" aria-labelledby=\"acf-field_61e53845c5a85-label\"><li><label class=\"selected\"><input type=\"radio\" id=\"acf-field_61e53845c5a85-oui\" name=\"acf[field_61e53845c5a85]\" value=\"Oui\" checked=\"checked\"\/>Oui<\/label><\/li><li><label><input type=\"radio\" id=\"acf-field_61e53845c5a85-non\" name=\"acf[field_61e53845c5a85]\" value=\"Non\"\/>Non<\/label><\/li><\/ul><\/div><\/div><div class=\"af-field af-field-type-page af-field- acf-field acf-field-page acf-field-61e538d2c5a86\" data-name=\"\" data-key=\"field_61e538d2c5a86\" data-type=\"page\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e538d2c5a86\">Informations compl\u00e9mentaires<\/label><\/div><div class=\"af-input acf-input\">    <a href=\"\" class=\"af-page-button\" data-key=\"field_61e538d2c5a86\" data-show-numbering=\"true\">\n      <span class=\"title\">Informations compl\u00e9mentaires<\/span>\n    <\/a>\n\n    <button class=\"af-previous-button\">Previous<\/button>\n    <button class=\"af-next-button\">Next<\/button>\n    <\/div><\/div><div class=\"af-field af-field-type-message af-field- acf-field acf-field-message acf-field-61e538e6c5a87\" data-name=\"\" data-key=\"field_61e538e6c5a87\" data-type=\"message\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e538e6c5a87\"><\/label><\/div><div class=\"af-input acf-input\"><h3>Informations compl\u00e9mentaires<\/h3>\n<\/div><\/div><div class=\"af-field af-field-type-textarea af-field-commemoratifs-et-antecedents acf-field acf-field-textarea acf-field-61e538f8c5a88 af-field-required\" data-name=\"commemoratifs_et_antecedents\" data-key=\"field_61e538f8c5a88\" data-type=\"textarea\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e538f8c5a88\">Comm\u00e9moratifs et ant\u00e9c\u00e9dents <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><textarea id=\"acf-field_61e538f8c5a88\" name=\"acf[field_61e538f8c5a88]\" rows=\"8\" required=\"required\"><\/textarea><\/div><\/div><div class=\"af-field af-field-type-textarea af-field-examens-realises acf-field acf-field-textarea acf-field-61e53906c5a8a af-field-required\" data-name=\"examens_realises\" data-key=\"field_61e53906c5a8a\" data-type=\"textarea\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e53906c5a8a\">Examens d\u00e9j\u00e0 r\u00e9alis\u00e9s \/ Traitements en cours : <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><textarea id=\"acf-field_61e53906c5a8a\" name=\"acf[field_61e53906c5a8a]\" rows=\"8\" required=\"required\"><\/textarea><\/div><\/div><div class=\"af-field af-field-type-textarea af-field-hypotheses-diagnostiques acf-field acf-field-textarea acf-field-61e53904c5a89 af-field-required\" data-name=\"hypotheses_diagnostiques\" data-key=\"field_61e53904c5a89\" data-type=\"textarea\"><div class=\"af-label acf-label\"><label for=\"acf-field_61e53904c5a89\">Hypoth\u00e8ses diagnostiques \/ Remarques (ant\u00e9c\u00e9dents - allergies) <span class=\"acf-required\">*<\/span><\/label><\/div><div class=\"af-input acf-input\"><textarea id=\"acf-field_61e53904c5a89\" name=\"acf[field_61e53904c5a89]\" rows=\"8\" required=\"required\"><\/textarea><\/div><\/div><div class=\"af-submit acf-form-submit\"><button type=\"submit\" class=\"acf-button af-submit-button\">Submit<\/button><span class=\"acf-spinner af-spinner\"><\/span><\/div><\/div><\/form>[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row css=&#8221;.vc_custom_1642755462108{background-color: #eeeeee !important;border-radius: 25px !important;}&#8221;][vc_column][vc_column_text] Pour toute demande de prise en charge, vous pouvez remplir le formulaire ci-dessous ou bien imprimer la version PDF. 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