{"id":1933,"date":"2025-02-25T14:30:27","date_gmt":"2025-02-25T14:30:27","guid":{"rendered":"https:\/\/cad.healthcare\/contact\/"},"modified":"2025-06-13T14:33:21","modified_gmt":"2025-06-13T14:33:21","slug":"contact","status":"publish","type":"page","link":"https:\/\/cad.healthcare\/fr\/contact\/","title":{"rendered":"Contact"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; admin_label=\u00a0\u00bbSezione\u00a0\u00bb module_id=\u00a0\u00bbintro\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; background_image=\u00a0\u00bbhttps:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/imgContatti-1.jpg\u00a0\u00bb background_position=\u00a0\u00bbtop_center\u00a0\u00bb background_vertical_offset=\u00a0\u00bb70%\u00a0\u00bb custom_margin=\u00a0\u00bb||||false|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||false|false\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row use_custom_gutter=\u00a0\u00bbon\u00a0\u00bb gutter_width=\u00a0\u00bb1&Prime; make_equal=\u00a0\u00bbon\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; background_color=\u00a0\u00bbrgba(33,61,89,0.52)\u00a0\u00bb width=\u00a0\u00bb100%\u00a0\u00bb custom_padding=\u00a0\u00bb148px||0px|1px|false|false\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb4.27.4&Prime; custom_padding=\u00a0\u00bb90px|60px|50px|111px|false|false\u00a0\u00bb custom_padding_tablet=\u00a0\u00bb140px|40px|20px|40px|false|false\u00a0\u00bb custom_padding_phone=\u00a0\u00bb0px|||22px|false|false\u00a0\u00bb custom_padding_last_edited=\u00a0\u00bbon|tablet\u00a0\u00bb custom_css_main_element=\u00a0\u00bbmargin-top:-100px\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbTitolo H1 introduzione sito\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; text_font=\u00a0\u00bb&#8211;et_global_body_font||||||||\u00a0\u00bb text_font_size=\u00a0\u00bb15px\u00a0\u00bb text_letter_spacing=\u00a0\u00bb0.5px\u00a0\u00bb text_line_height=\u00a0\u00bb1.4em\u00a0\u00bb header_font=\u00a0\u00bb&#8211;et_global_body_font||||||||\u00a0\u00bb header_text_color=\u00a0\u00bb#FFFFFF\u00a0\u00bb header_font_size=\u00a0\u00bb80px\u00a0\u00bb header_2_font=\u00a0\u00bbNunito||||||||\u00a0\u00bb header_2_text_color=\u00a0\u00bb#FFFFFF\u00a0\u00bb header_2_font_size=\u00a0\u00bb42px\u00a0\u00bb custom_margin=\u00a0\u00bb||30px||false|false\u00a0\u00bb custom_padding=\u00a0\u00bb|0px||||\u00a0\u00bb animation_style=\u00a0\u00bbslide\u00a0\u00bb animation_direction=\u00a0\u00bbbottom\u00a0\u00bb animation_intensity_slide=\u00a0\u00bb5%\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n<h1><b>Avez-vous besoin de<\/b> l&rsquo;aide de<br \/>\n <b>?<\/b><\/span><\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1&Prime; module_id=\u00a0\u00bbintro\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; custom_margin=\u00a0\u00bb||0px||false|false\u00a0\u00bb custom_padding=\u00a0\u00bb16px||9px|||\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row column_structure=\u00a0\u00bb1_2,1_2&Prime; use_custom_gutter=\u00a0\u00bbon\u00a0\u00bb gutter_width=\u00a0\u00bb1&Prime; custom_padding_last_edited=\u00a0\u00bbon|tablet\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; width=\u00a0\u00bb90%\u00a0\u00bb custom_padding=\u00a0\u00bb53px||0px|||\u00a0\u00bb custom_padding_tablet=\u00a0\u00bb0px||||false|false\u00a0\u00bb custom_padding_phone=\u00a0\u00bb0px||||false|false\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb1_2&Prime; _builder_version=\u00a0\u00bb4.27.4&Prime; custom_padding=\u00a0\u00bb0px||70px||false|false\u00a0\u00bb custom_padding_tablet=\u00a0\u00bb0px||70px||false|false\u00a0\u00bb custom_padding_phone=\u00a0\u00bb0px|10px|50px|10px|false|false\u00a0\u00bb custom_padding_last_edited=\u00a0\u00bbon|phone\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbI nostri articoli\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; text_font_size=\u00a0\u00bb20px\u00a0\u00bb header_2_font=\u00a0\u00bbNunito|600|||||||\u00a0\u00bb header_2_font_size=\u00a0\u00bb50px\u00a0\u00bb header_3_text_color=\u00a0\u00bb#213D59&Prime; header_3_font_size=\u00a0\u00bb34px\u00a0\u00bb header_4_line_height=\u00a0\u00bb1.1em\u00a0\u00bb custom_margin=\u00a0\u00bb59px|||||\u00a0\u00bb custom_margin_tablet=\u00a0\u00bb59px|||||\u00a0\u00bb custom_margin_phone=\u00a0\u00bb40px||||false|false\u00a0\u00bb custom_margin_last_edited=\u00a0\u00bbon|phone\u00a0\u00bb custom_padding=\u00a0\u00bb|0px||||\u00a0\u00bb animation_style=\u00a0\u00bbslide\u00a0\u00bb animation_direction=\u00a0\u00bbleft\u00a0\u00bb animation_intensity_slide=\u00a0\u00bb5%\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n<p>Nous sommes \u00e0 votre disposition pour r\u00e9pondre \u00e0 vos questions et \u00e9valuer ensemble la solution la plus adapt\u00e9e \u00e0 vos besoins de services.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][et_pb_column type=\u00a0\u00bb1_2&Prime; _builder_version=\u00a0\u00bb4.27.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text admin_label=\u00a0\u00bbTitolo H1 introduzione sito\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; text_font=\u00a0\u00bb&#8211;et_global_body_font||||||||\u00a0\u00bb text_font_size=\u00a0\u00bb15px\u00a0\u00bb text_letter_spacing=\u00a0\u00bb0.5px\u00a0\u00bb text_line_height=\u00a0\u00bb1.4em\u00a0\u00bb link_text_color=\u00a0\u00bb#71C9FF\u00a0\u00bb header_font=\u00a0\u00bbHelvetica Neue Bold||||||||\u00a0\u00bb header_font_size=\u00a0\u00bb80px\u00a0\u00bb text_orientation=\u00a0\u00bbright\u00a0\u00bb max_width=\u00a0\u00bb74%\u00a0\u00bb module_alignment=\u00a0\u00bbright\u00a0\u00bb custom_margin=\u00a0\u00bb54px||21px||false|false\u00a0\u00bb custom_margin_tablet=\u00a0\u00bb0px||21px||false|false\u00a0\u00bb custom_margin_phone=\u00a0\u00bb0px||21px||false|false\u00a0\u00bb custom_margin_last_edited=\u00a0\u00bbon|tablet\u00a0\u00bb animation_style=\u00a0\u00bbfade\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n<h3><a href=\"tel:41919719794\"><strong>+41 91 971 97 94<\/strong><\/a><br \/><strong><a href=\"mailto:info@cad.healthcare\">info@cad.healthcare<\/a><\/strong><br \/><strong>Lugano (CH)<\/strong><\/h3>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1&Prime; module_id=\u00a0\u00bbcontactPatient\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb background_color=\u00a0\u00bb#F6F6F6&Prime; custom_margin=\u00a0\u00bb-2px|||||\u00a0\u00bb custom_padding=\u00a0\u00bb36px|||||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row use_custom_gutter=\u00a0\u00bbon\u00a0\u00bb gutter_width=\u00a0\u00bb1&Prime; _builder_version=\u00a0\u00bb4.27.4&Prime; width=\u00a0\u00bb90%\u00a0\u00bb custom_padding=\u00a0\u00bb24px||0px||false|false\u00a0\u00bb locked=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb4.27.4&Prime; custom_padding=\u00a0\u00bb|80px|||false|false\u00a0\u00bb custom_padding_tablet=\u00a0\u00bb|80px|||false|false\u00a0\u00bb custom_padding_phone=\u00a0\u00bb|0px|||false|false\u00a0\u00bb custom_padding_last_edited=\u00a0\u00bbon|phone\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_text content_tablet=\u00a0\u00bb<\/p>\n<h2 class=%22p1%22>Veuillez s\u00e9lectionner le type de <b>contact dont vous avez besoin<\/b>.<\/h2>\n<p>\u00a0\u00bb content_phone=\u00a0\u00bb<\/p>\n<h2 class=%22p1%22>Veuillez s\u00e9lectionner le type de <b>contact dont vous avez besoin<\/b>.<\/h2>\n<p>\u00a0\u00bb content_last_edited=\u00a0\u00bboff|desktop\u00a0\u00bb admin_label=\u00a0\u00bbI nostri articoli\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; header_2_font=\u00a0\u00bbNunito|600|||||||\u00a0\u00bb header_2_font_size=\u00a0\u00bb50px\u00a0\u00bb header_3_text_color=\u00a0\u00bb#213D59&Prime; header_3_font_size=\u00a0\u00bb34px\u00a0\u00bb custom_margin=\u00a0\u00bb10px|||||\u00a0\u00bb custom_padding=\u00a0\u00bb|42px||||\u00a0\u00bb custom_padding_tablet=\u00a0\u00bb|42px||||\u00a0\u00bb custom_padding_phone=\u00a0\u00bb|0px|||false|false\u00a0\u00bb custom_padding_last_edited=\u00a0\u00bbon|phone\u00a0\u00bb animation_style=\u00a0\u00bbslide\u00a0\u00bb animation_direction=\u00a0\u00bbleft\u00a0\u00bb animation_intensity_slide=\u00a0\u00bb5%\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<\/p>\n<h2 class=\"p1\">S\u00e9lectionnez le<b>formulaire de contact<\/b><\/p>\n<p> dont vous avez besoin.<\/h2>\n<p>[\/et_pb_text][wpforms_selector form_id=\u00a0\u00bb58&Prime; module_class=\u00a0\u00bbformScelta\u00a0\u00bb _builder_version=\u00a0\u00bb4.27.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][\/wpforms_selector][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Avez-vous besoin de l&rsquo;aide de ?Nous sommes \u00e0 votre disposition pour r\u00e9pondre \u00e0 vos questions et \u00e9valuer ensemble la solution la plus adapt\u00e9e \u00e0 vos besoins de services.+41 91 971 97 94info@cad.healthcareLugano (CH)S\u00e9lectionnez leformulaire de contact dont vous avez besoin.<div class=\"et_pb_module wpforms_selector wpforms_selector_0 formScelta\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<div class=\"wpforms-container wpforms-container-full stileNormale\" id=\"wpforms-58\"><form id=\"wpforms-form-58\" class=\"wpforms-validate wpforms-form\" data-formid=\"58\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/1933\" data-token=\"afd978547aa12148b817acc2dc58ce66\" data-token-time=\"1777965571\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-58-field_9-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"9\"><label class=\"wpforms-field-label wpforms-label-hide\">Type de contact requis : <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_9\" class=\"wpforms-field-required wpforms-image-choices wpforms-image-choices-modern\"><li class=\"choice-1 depth-1 wpforms-image-choices-item wpforms-selected\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_1\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icona-modulo-contatti.png\" alt=\"Contact Patients\" title=\"Contact Patients\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_1\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Contact Patients\" tabindex=\"-1\" required  checked='checked'><span class=\"wpforms-image-choices-label\">Contact Patients<\/span><\/label><\/li><li class=\"choice-2 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_2\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icone-srtuttura-contatti.png\" alt=\"Contact H\u00f4pitaux\/Cliniques\" title=\"Contact H\u00f4pitaux\/Cliniques\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_2\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Contact H\u00f4pitaux\/Cliniques\" tabindex=\"-1\" required ><span class=\"wpforms-image-choices-label\">Contact H\u00f4pitaux\/Cliniques<\/span><\/label><\/li><li class=\"choice-3 depth-1 wpforms-image-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_9_3\" tabindex=\"0\"><span class=\"wpforms-image-choices-image\"><img decoding=\"async\" src=\"https:\/\/cad.healthcare\/wp-content\/uploads\/2025\/03\/icona-medico-curante-contatti.png\" alt=\"Contact M\u00e9decin Traitant\" title=\"Contact M\u00e9decin Traitant\"><\/span><input type=\"radio\" id=\"wpforms-58-field_9_3\" class=\"wpforms-screen-reader-element\" name=\"wpforms[fields][9]\" value=\"Contact M\u00e9decin Traitant\" tabindex=\"-1\" required ><span class=\"wpforms-image-choices-label\">Contact M\u00e9decin Traitant<\/span><\/label><\/li><\/ul><\/div><div id=\"wpforms-58-field_10-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"10\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDonn\u00e9es sur les patients\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_3-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"3\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_3\">Pr\u00e9nom Nom de famille <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"Nom et pr\u00e9nom\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_13-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"13\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_13\">Date de naissance <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_13\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][13][date]\" placeholder=\"Date de naissance\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_105-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"105\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_105\">Nation<\/label><select id=\"wpforms-58-field_105\" class=\"wpforms-field-large\" name=\"wpforms[fields][105]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanie\"  class=\"choice-5 depth-1\"  >Albanie<\/option><option value=\"Alg\u00e9rie\"  class=\"choice-6 depth-1\"  >Alg\u00e9rie<\/option><option value=\"Andorre\"  class=\"choice-7 depth-1\"  >Andorre<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarctique\"  class=\"choice-10 depth-1\"  >Antarctique<\/option><option value=\"Antigua et Barbuda\"  class=\"choice-11 depth-1\"  >Antigua et Barbuda<\/option><option value=\"Arabie Saoudite\"  class=\"choice-12 depth-1\"  >Arabie Saoudite<\/option><option value=\"Argentine\"  class=\"choice-13 depth-1\"  >Argentine<\/option><option value=\"Arm\u00e9nie\"  class=\"choice-14 depth-1\"  >Arm\u00e9nie<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australie\"  class=\"choice-16 depth-1\"  >Australie<\/option><option value=\"Autriche\"  class=\"choice-17 depth-1\"  >Autriche<\/option><option value=\"Azerba\u00efdjan\"  class=\"choice-18 depth-1\"  >Azerba\u00efdjan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahre\u00efn\"  class=\"choice-20 depth-1\"  >Bahre\u00efn<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbade\"  class=\"choice-22 depth-1\"  >Barbade<\/option><option value=\"Belgique\"  class=\"choice-23 depth-1\"  >Belgique<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"B\u00e9nin\"  class=\"choice-25 depth-1\"  >B\u00e9nin<\/option><option value=\"Bermudes\"  class=\"choice-26 depth-1\"  >Bermudes<\/option><option value=\"Bhoutan\"  class=\"choice-27 depth-1\"  >Bhoutan<\/option><option value=\"B\u00e9larus\"  class=\"choice-28 depth-1\"  >B\u00e9larus<\/option><option value=\"Birmanie\"  class=\"choice-29 depth-1\"  >Birmanie<\/option><option value=\"Bolivie (\u00c9tat plurinational de)\"  class=\"choice-30 depth-1\"  >Bolivie (\u00c9tat plurinational de)<\/option><option value=\"Bonaire, Saint-Eustache et Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint-Eustache et Saba<\/option><option value=\"Bosnie et Herz\u00e9govine\"  class=\"choice-32 depth-1\"  >Bosnie et Herz\u00e9govine<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Br\u00e9sil\"  class=\"choice-34 depth-1\"  >Br\u00e9sil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarie\"  class=\"choice-36 depth-1\"  >Bulgarie<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodge\"  class=\"choice-39 depth-1\"  >Cambodge<\/option><option value=\"Cameroun\"  class=\"choice-40 depth-1\"  >Cameroun<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cap Vert\"  class=\"choice-42 depth-1\"  >Cap Vert<\/option><option value=\"Tchad\"  class=\"choice-43 depth-1\"  >Tchad<\/option><option value=\"Chili\"  class=\"choice-44 depth-1\"  >Chili<\/option><option value=\"Chine\"  class=\"choice-45 depth-1\"  >Chine<\/option><option value=\"Chypre\"  class=\"choice-46 depth-1\"  >Chypre<\/option><option value=\"Colombie\"  class=\"choice-47 depth-1\"  >Colombie<\/option><option value=\"Comores\"  class=\"choice-48 depth-1\"  >Comores<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (R\u00e9publique d\u00e9mocratique du)\"  class=\"choice-50 depth-1\"  >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\"  class=\"choice-52 depth-1\"  >C\u00f4te d'Ivoire<\/option><option value=\"Croatie\"  class=\"choice-53 depth-1\"  >Croatie<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Danemark\"  class=\"choice-56 depth-1\"  >Danemark<\/option><option value=\"Dominique\"  class=\"choice-57 depth-1\"  >Dominique<\/option><option value=\"\u00c9quateur\"  class=\"choice-58 depth-1\"  >\u00c9quateur<\/option><option value=\"\u00c9gypte\"  class=\"choice-59 depth-1\"  >\u00c9gypte<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"\u00c9mirats arabes unis\"  class=\"choice-61 depth-1\"  >\u00c9mirats arabes unis<\/option><option value=\"Erythr\u00e9e\"  class=\"choice-62 depth-1\"  >Erythr\u00e9e<\/option><option value=\"Estonie\"  class=\"choice-63 depth-1\"  >Estonie<\/option><option value=\"\u00c9thiopie\"  class=\"choice-64 depth-1\"  >\u00c9thiopie<\/option><option value=\"F\u00e9d\u00e9ration de Russie\"  class=\"choice-65 depth-1\"  >F\u00e9d\u00e9ration de Russie<\/option><option value=\"Fidji\"  class=\"choice-66 depth-1\"  >Fidji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finlande\"  class=\"choice-68 depth-1\"  >Finlande<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambie\"  class=\"choice-71 depth-1\"  >Gambie<\/option><option value=\"G\u00e9orgie\"  class=\"choice-72 depth-1\"  >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et \u00eeles Sandwich du Sud\"  class=\"choice-73 depth-1\"  >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"Allemagne\"  class=\"choice-74 depth-1\"  >Allemagne<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jama\u00efque\"  class=\"choice-76 depth-1\"  >Jama\u00efque<\/option><option value=\"Japon\"  class=\"choice-77 depth-1\"  >Japon<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordanie\"  class=\"choice-80 depth-1\"  >Jordanie<\/option><option value=\"Gr\u00e8ce\"  class=\"choice-81 depth-1\"  >Gr\u00e8ce<\/option><option value=\"Grenade\"  class=\"choice-82 depth-1\"  >Grenade<\/option><option value=\"Groenland\"  class=\"choice-83 depth-1\"  >Groenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernesey\"  class=\"choice-87 depth-1\"  >Guernesey<\/option><option value=\"Guyane fran\u00e7aise\"  class=\"choice-88 depth-1\"  >Guyane fran\u00e7aise<\/option><option value=\"Guin\u00e9e\"  class=\"choice-89 depth-1\"  >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00e9quatoriale\"  class=\"choice-90 depth-1\"  >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\"  class=\"choice-91 depth-1\"  >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\"  class=\"choice-92 depth-1\"  >Guyane<\/option><option value=\"Ha\u00efti\"  class=\"choice-93 depth-1\"  >Ha\u00efti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"Inde\"  class=\"choice-96 depth-1\"  >Inde<\/option><option value=\"Indon\u00e9sie\"  class=\"choice-97 depth-1\"  >Indon\u00e9sie<\/option><option value=\"Iran (R\u00e9publique islamique d&#039;)\"  class=\"choice-98 depth-1\"  >Iran (R\u00e9publique islamique d')<\/option><option value=\"L&#039;Irak\"  class=\"choice-99 depth-1\"  >L'Irak<\/option><option value=\"Irlande (R\u00e9publique d&#039;)\"  class=\"choice-100 depth-1\"  >Irlande (R\u00e9publique d')<\/option><option value=\"Islande\"  class=\"choice-101 depth-1\"  >Islande<\/option><option value=\"\u00cele Bouvet\"  class=\"choice-102 depth-1\"  >\u00cele Bouvet<\/option><option value=\"\u00cele de Man\"  class=\"choice-103 depth-1\"  >\u00cele de Man<\/option><option value=\"L&#039;\u00eele de No\u00ebl\"  class=\"choice-104 depth-1\"  >L'\u00eele de No\u00ebl<\/option><option value=\"\u00cele de Saint-Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >\u00cele de Saint-Barth\u00e9lemy<\/option><option value=\"Aland (\u00celes)\"  class=\"choice-106 depth-1\"  >Aland (\u00celes)<\/option><option value=\"\u00celes Ca\u00efmans\"  class=\"choice-107 depth-1\"  >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos (Keeling)\"  class=\"choice-108 depth-1\"  >\u00celes Cocos (Keeling)<\/option><option value=\"\u00celes Cook\"  class=\"choice-109 depth-1\"  >\u00celes Cook<\/option><option value=\"\u00celes Malouines (Malvinas)\"  class=\"choice-110 depth-1\"  >\u00celes Malouines (Malvinas)<\/option><option value=\"\u00celes F\u00e9ro\u00e9\"  class=\"choice-111 depth-1\"  >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Heard et McDonald\"  class=\"choice-112 depth-1\"  >\u00celes Heard et McDonald<\/option><option value=\"Mariannes du Nord (\u00celes)\"  class=\"choice-113 depth-1\"  >Mariannes du Nord (\u00celes)<\/option><option value=\"\u00celes Marshall\"  class=\"choice-114 depth-1\"  >\u00celes Marshall<\/option><option value=\"\u00celes Norfolk\"  class=\"choice-115 depth-1\"  >\u00celes Norfolk<\/option><option value=\"Saint-Pierre et Miquelon (\u00celes)\"  class=\"choice-116 depth-1\"  >Saint-Pierre et Miquelon (\u00celes)<\/option><option value=\"\u00celes Salomon\"  class=\"choice-117 depth-1\"  >\u00celes Salomon<\/option><option value=\"Svalbard et \u00eeles Jan Mayen\"  class=\"choice-118 depth-1\"  >Svalbard et \u00eeles Jan Mayen<\/option><option value=\"\u00celes Turks et Caicos\"  class=\"choice-119 depth-1\"  >\u00celes Turks et Caicos<\/option><option value=\"\u00celes Vierges (US)\"  class=\"choice-120 depth-1\"  >\u00celes Vierges (US)<\/option><option value=\"\u00celes Vierges (britanniques)\"  class=\"choice-121 depth-1\"  >\u00celes Vierges (britanniques)<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\"  class=\"choice-122 depth-1\"  >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value=\"Isra\u00ebl\"  class=\"choice-123 depth-1\"  >Isra\u00ebl<\/option><option value=\"Italie\"  class=\"choice-124 depth-1\"  >Italie<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kirghizistan\"  class=\"choice-127 depth-1\"  >Kirghizistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)\"  class=\"choice-129 depth-1\"  >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value=\"Cor\u00e9e (R\u00e9publique de)\"  class=\"choice-130 depth-1\"  >Cor\u00e9e (R\u00e9publique de)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kowe\u00eft\"  class=\"choice-132 depth-1\"  >Kowe\u00eft<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettonie\"  class=\"choice-134 depth-1\"  >Lettonie<\/option><option value=\"Liban\"  class=\"choice-135 depth-1\"  >Liban<\/option><option value=\"Lib\u00e9ria\"  class=\"choice-136 depth-1\"  >Lib\u00e9ria<\/option><option value=\"Libye\"  class=\"choice-137 depth-1\"  >Libye<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lituanie\"  class=\"choice-139 depth-1\"  >Lituanie<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Mac\u00e9doine du Nord (R\u00e9publique de)\"  class=\"choice-142 depth-1\"  >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaisie\"  class=\"choice-147 depth-1\"  >Malaisie<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malte\"  class=\"choice-149 depth-1\"  >Malte<\/option><option value=\"Maroc\"  class=\"choice-150 depth-1\"  >Maroc<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritanie\"  class=\"choice-152 depth-1\"  >Mauritanie<\/option><option value=\"Maurice\"  class=\"choice-153 depth-1\"  >Maurice<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexique\"  class=\"choice-155 depth-1\"  >Mexique<\/option><option value=\"Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)\"  class=\"choice-156 depth-1\"  >Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)<\/option><option value=\"Moldavie (R\u00e9publique de)\"  class=\"choice-157 depth-1\"  >Moldavie (R\u00e9publique de)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolie\"  class=\"choice-159 depth-1\"  >Mongolie<\/option><option value=\"Mont\u00e9n\u00e9gro\"  class=\"choice-160 depth-1\"  >Mont\u00e9n\u00e9gro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibie\"  class=\"choice-163 depth-1\"  >Namibie<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"N\u00e9pal\"  class=\"choice-165 depth-1\"  >N\u00e9pal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nig\u00e9ria\"  class=\"choice-168 depth-1\"  >Nig\u00e9ria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norv\u00e8ge\"  class=\"choice-170 depth-1\"  >Norv\u00e8ge<\/option><option value=\"Nouvelle-Cal\u00e9donie\"  class=\"choice-171 depth-1\"  >Nouvelle-Cal\u00e9donie<\/option><option value=\"Nouvelle-Z\u00e9lande\"  class=\"choice-172 depth-1\"  >Nouvelle-Z\u00e9lande<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Les Pays-Bas\"  class=\"choice-174 depth-1\"  >Les Pays-Bas<\/option><option value=\"Le Pakistan\"  class=\"choice-175 depth-1\"  >Le Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (\u00c9tat de)\"  class=\"choice-177 depth-1\"  >Palestine (\u00c9tat de)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\"  class=\"choice-179 depth-1\"  >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"P\u00e9rou\"  class=\"choice-181 depth-1\"  >P\u00e9rou<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Pologne\"  class=\"choice-183 depth-1\"  >Pologne<\/option><option value=\"Polyn\u00e9sie fran\u00e7aise\"  class=\"choice-184 depth-1\"  >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"Porto Rico\"  class=\"choice-185 depth-1\"  >Porto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"Royaume-Uni de Grande-Bretagne et d&#039;Irlande du Nord\"  class=\"choice-188 depth-1\"  >Royaume-Uni de Grande-Bretagne et d'Irlande du Nord<\/option><option value=\"R\u00e9publique arabe de Syrie\"  class=\"choice-189 depth-1\"  >R\u00e9publique arabe de Syrie<\/option><option value=\"R\u00e9publique tch\u00e8que\"  class=\"choice-190 depth-1\"  >R\u00e9publique tch\u00e8que<\/option><option value=\"R\u00e9publique centrafricaine\"  class=\"choice-191 depth-1\"  >R\u00e9publique centrafricaine<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire lao\"  class=\"choice-192 depth-1\"  >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value=\"R\u00e9publique dominicaine\"  class=\"choice-193 depth-1\"  >R\u00e9publique dominicaine<\/option><option value=\"R\u00e9union (\u00cele de)\"  class=\"choice-194 depth-1\"  >R\u00e9union (\u00cele de)<\/option><option value=\"Roumanie\"  class=\"choice-195 depth-1\"  >Roumanie<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Sahara occidental\"  class=\"choice-197 depth-1\"  >Sahara occidental<\/option><option value=\"Saint-Kitts-et-Nevis\"  class=\"choice-198 depth-1\"  >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Vincent-et-les-Grenadines\"  class=\"choice-199 depth-1\"  >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Saint-Martin (partie fran\u00e7aise)\"  class=\"choice-200 depth-1\"  >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\"  class=\"choice-202 depth-1\"  >Samoa am\u00e9ricaines<\/option><option value=\"Saint-Marin\"  class=\"choice-203 depth-1\"  >Saint-Marin<\/option><option value=\"Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha\"  class=\"choice-204 depth-1\"  >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"Sainte-Lucie\"  class=\"choice-205 depth-1\"  >Sainte-Lucie<\/option><option value=\"Sao Tom\u00e9 et Principe\"  class=\"choice-206 depth-1\"  >Sao Tom\u00e9 et Principe<\/option><option value=\"S\u00e9n\u00e9gal\"  class=\"choice-207 depth-1\"  >S\u00e9n\u00e9gal<\/option><option value=\"Serbie\"  class=\"choice-208 depth-1\"  >Serbie<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapour\"  class=\"choice-211 depth-1\"  >Singapour<\/option><option value=\"Sint Maarten (partie des Pays-Bas)\"  class=\"choice-212 depth-1\"  >Sint Maarten (partie des Pays-Bas)<\/option><option value=\"Slovaquie\"  class=\"choice-213 depth-1\"  >Slovaquie<\/option><option value=\"Slov\u00e9nie\"  class=\"choice-214 depth-1\"  >Slov\u00e9nie<\/option><option value=\"Somalie\"  class=\"choice-215 depth-1\"  >Somalie<\/option><option value=\"Espagne\"  class=\"choice-216 depth-1\"  >Espagne<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"\u00c9tats-Unis d&#039;Am\u00e9rique\"  class=\"choice-218 depth-1\"  >\u00c9tats-Unis d'Am\u00e9rique<\/option><option value=\"\u00c9tat de la Cit\u00e9 du Vatican\"  class=\"choice-219 depth-1\"  >\u00c9tat de la Cit\u00e9 du Vatican<\/option><option value=\"Afrique du Sud\"  class=\"choice-220 depth-1\"  >Afrique du Sud<\/option><option value=\"Soudan\"  class=\"choice-221 depth-1\"  >Soudan<\/option><option value=\"Sud Soudan\"  class=\"choice-222 depth-1\"  >Sud Soudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Su\u00e8de\"  class=\"choice-224 depth-1\"  >Su\u00e8de<\/option><option value=\"Suisse\"  selected='selected' class=\"choice-225 depth-1\"  >Suisse<\/option><option value=\"Tadjikistan\"  class=\"choice-226 depth-1\"  >Tadjikistan<\/option><option value=\"Ta\u00efwan, R\u00e9publique de Chine\"  class=\"choice-227 depth-1\"  >Ta\u00efwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie (R\u00e9publique-Unie de)\"  class=\"choice-228 depth-1\"  >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"Les Terres australes fran\u00e7aises\"  class=\"choice-229 depth-1\"  >Les Terres australes fran\u00e7aises<\/option><option value=\"Territoire britannique dans l&#039;oc\u00e9an Indien\"  class=\"choice-230 depth-1\"  >Territoire britannique dans l'oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\"  class=\"choice-231 depth-1\"  >Tha\u00eflande<\/option><option value=\"Timor oriental\"  class=\"choice-232 depth-1\"  >Timor oriental<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinit\u00e9-et-Tobago\"  class=\"choice-236 depth-1\"  >Trinit\u00e9-et-Tobago<\/option><option value=\"Tunisie\"  class=\"choice-237 depth-1\"  >Tunisie<\/option><option value=\"Turquie\"  class=\"choice-238 depth-1\"  >Turquie<\/option><option value=\"Turkm\u00e9nistan\"  class=\"choice-239 depth-1\"  >Turkm\u00e9nistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Ouganda\"  class=\"choice-242 depth-1\"  >Ouganda<\/option><option value=\"Hongrie\"  class=\"choice-243 depth-1\"  >Hongrie<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Ouzb\u00e9kistan\"  class=\"choice-245 depth-1\"  >Ouzb\u00e9kistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (R\u00e9publique bolivarienne du)\"  class=\"choice-247 depth-1\"  >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis et Futuna\"  class=\"choice-249 depth-1\"  >Wallis et Futuna<\/option><option value=\"Y\u00e9men\"  class=\"choice-250 depth-1\"  >Y\u00e9men<\/option><option value=\"Zambie\"  class=\"choice-251 depth-1\"  >Zambie<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Royaume de)\"  class=\"choice-253 depth-1\"  >eSwatini (Royaume de)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_12-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"12\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_12\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_12\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][12][address1]\" placeholder=\"Adresse\" required><label for=\"wpforms-58-field_12\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_12-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][12][city]\" placeholder=\"Villes\" required><label for=\"wpforms-58-field_12-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_12-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][12][state]\" placeholder=\"Canton\" required><label for=\"wpforms-58-field_12-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_4-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"4\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_4\">T\u00e9l\u00e9phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_4\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][4]\" placeholder=\"T\u00e9l\u00e9phone\" aria-label=\"T\u00e9l\u00e9phone\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_1-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"1\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_1\">Courriel<\/label><input type=\"email\" id=\"wpforms-58-field_1\" class=\"wpforms-field-large\" name=\"wpforms[fields][1]\" placeholder=\"Courriel\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_14-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"14\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tCoordonn\u00e9es (si diff\u00e9rentes de celles du patient)\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_21-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_21\">pr\u00e9nom nom<\/label><input type=\"text\" id=\"wpforms-58-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" placeholder=\"Nom et pr\u00e9nom\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_16-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"16\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_16\">Date de naissance<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_16\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][16][date]\" placeholder=\"Date de naissance\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_107-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"107\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_107\">Pays Contact<\/label><select id=\"wpforms-58-field_107\" class=\"wpforms-field-large\" name=\"wpforms[fields][107]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanie\"  class=\"choice-5 depth-1\"  >Albanie<\/option><option value=\"Alg\u00e9rie\"  class=\"choice-6 depth-1\"  >Alg\u00e9rie<\/option><option value=\"Andorre\"  class=\"choice-7 depth-1\"  >Andorre<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarctique\"  class=\"choice-10 depth-1\"  >Antarctique<\/option><option value=\"Antigua et Barbuda\"  class=\"choice-11 depth-1\"  >Antigua et Barbuda<\/option><option value=\"Arabie Saoudite\"  class=\"choice-12 depth-1\"  >Arabie Saoudite<\/option><option value=\"Argentine\"  class=\"choice-13 depth-1\"  >Argentine<\/option><option value=\"Arm\u00e9nie\"  class=\"choice-14 depth-1\"  >Arm\u00e9nie<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australie\"  class=\"choice-16 depth-1\"  >Australie<\/option><option value=\"Autriche\"  class=\"choice-17 depth-1\"  >Autriche<\/option><option value=\"Azerba\u00efdjan\"  class=\"choice-18 depth-1\"  >Azerba\u00efdjan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahre\u00efn\"  class=\"choice-20 depth-1\"  >Bahre\u00efn<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbade\"  class=\"choice-22 depth-1\"  >Barbade<\/option><option value=\"Belgique\"  class=\"choice-23 depth-1\"  >Belgique<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"B\u00e9nin\"  class=\"choice-25 depth-1\"  >B\u00e9nin<\/option><option value=\"Bermudes\"  class=\"choice-26 depth-1\"  >Bermudes<\/option><option value=\"Bhoutan\"  class=\"choice-27 depth-1\"  >Bhoutan<\/option><option value=\"B\u00e9larus\"  class=\"choice-28 depth-1\"  >B\u00e9larus<\/option><option value=\"Birmanie\"  class=\"choice-29 depth-1\"  >Birmanie<\/option><option value=\"Bolivie (\u00c9tat plurinational de)\"  class=\"choice-30 depth-1\"  >Bolivie (\u00c9tat plurinational de)<\/option><option value=\"Bonaire, Saint-Eustache et Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint-Eustache et Saba<\/option><option value=\"Bosnie et Herz\u00e9govine\"  class=\"choice-32 depth-1\"  >Bosnie et Herz\u00e9govine<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Br\u00e9sil\"  class=\"choice-34 depth-1\"  >Br\u00e9sil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarie\"  class=\"choice-36 depth-1\"  >Bulgarie<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodge\"  class=\"choice-39 depth-1\"  >Cambodge<\/option><option value=\"Cameroun\"  class=\"choice-40 depth-1\"  >Cameroun<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cap Vert\"  class=\"choice-42 depth-1\"  >Cap Vert<\/option><option value=\"Tchad\"  class=\"choice-43 depth-1\"  >Tchad<\/option><option value=\"Chili\"  class=\"choice-44 depth-1\"  >Chili<\/option><option value=\"Chine\"  class=\"choice-45 depth-1\"  >Chine<\/option><option value=\"Chypre\"  class=\"choice-46 depth-1\"  >Chypre<\/option><option value=\"Colombie\"  class=\"choice-47 depth-1\"  >Colombie<\/option><option value=\"Comores\"  class=\"choice-48 depth-1\"  >Comores<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (R\u00e9publique d\u00e9mocratique du)\"  class=\"choice-50 depth-1\"  >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\"  class=\"choice-52 depth-1\"  >C\u00f4te d'Ivoire<\/option><option value=\"Croatie\"  class=\"choice-53 depth-1\"  >Croatie<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Danemark\"  class=\"choice-56 depth-1\"  >Danemark<\/option><option value=\"Dominique\"  class=\"choice-57 depth-1\"  >Dominique<\/option><option value=\"\u00c9quateur\"  class=\"choice-58 depth-1\"  >\u00c9quateur<\/option><option value=\"\u00c9gypte\"  class=\"choice-59 depth-1\"  >\u00c9gypte<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"\u00c9mirats arabes unis\"  class=\"choice-61 depth-1\"  >\u00c9mirats arabes unis<\/option><option value=\"Erythr\u00e9e\"  class=\"choice-62 depth-1\"  >Erythr\u00e9e<\/option><option value=\"Estonie\"  class=\"choice-63 depth-1\"  >Estonie<\/option><option value=\"\u00c9thiopie\"  class=\"choice-64 depth-1\"  >\u00c9thiopie<\/option><option value=\"F\u00e9d\u00e9ration de Russie\"  class=\"choice-65 depth-1\"  >F\u00e9d\u00e9ration de Russie<\/option><option value=\"Fidji\"  class=\"choice-66 depth-1\"  >Fidji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finlande\"  class=\"choice-68 depth-1\"  >Finlande<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambie\"  class=\"choice-71 depth-1\"  >Gambie<\/option><option value=\"G\u00e9orgie\"  class=\"choice-72 depth-1\"  >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et \u00eeles Sandwich du Sud\"  class=\"choice-73 depth-1\"  >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"Allemagne\"  class=\"choice-74 depth-1\"  >Allemagne<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jama\u00efque\"  class=\"choice-76 depth-1\"  >Jama\u00efque<\/option><option value=\"Japon\"  class=\"choice-77 depth-1\"  >Japon<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordanie\"  class=\"choice-80 depth-1\"  >Jordanie<\/option><option value=\"Gr\u00e8ce\"  class=\"choice-81 depth-1\"  >Gr\u00e8ce<\/option><option value=\"Grenade\"  class=\"choice-82 depth-1\"  >Grenade<\/option><option value=\"Groenland\"  class=\"choice-83 depth-1\"  >Groenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernesey\"  class=\"choice-87 depth-1\"  >Guernesey<\/option><option value=\"Guyane fran\u00e7aise\"  class=\"choice-88 depth-1\"  >Guyane fran\u00e7aise<\/option><option value=\"Guin\u00e9e\"  class=\"choice-89 depth-1\"  >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00e9quatoriale\"  class=\"choice-90 depth-1\"  >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\"  class=\"choice-91 depth-1\"  >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\"  class=\"choice-92 depth-1\"  >Guyane<\/option><option value=\"Ha\u00efti\"  class=\"choice-93 depth-1\"  >Ha\u00efti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"Inde\"  class=\"choice-96 depth-1\"  >Inde<\/option><option value=\"Indon\u00e9sie\"  class=\"choice-97 depth-1\"  >Indon\u00e9sie<\/option><option value=\"Iran (R\u00e9publique islamique d&#039;)\"  class=\"choice-98 depth-1\"  >Iran (R\u00e9publique islamique d')<\/option><option value=\"L&#039;Irak\"  class=\"choice-99 depth-1\"  >L'Irak<\/option><option value=\"Irlande (R\u00e9publique d&#039;)\"  class=\"choice-100 depth-1\"  >Irlande (R\u00e9publique d')<\/option><option value=\"Islande\"  class=\"choice-101 depth-1\"  >Islande<\/option><option value=\"\u00cele Bouvet\"  class=\"choice-102 depth-1\"  >\u00cele Bouvet<\/option><option value=\"\u00cele de Man\"  class=\"choice-103 depth-1\"  >\u00cele de Man<\/option><option value=\"L&#039;\u00eele de No\u00ebl\"  class=\"choice-104 depth-1\"  >L'\u00eele de No\u00ebl<\/option><option value=\"\u00cele de Saint-Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >\u00cele de Saint-Barth\u00e9lemy<\/option><option value=\"Aland (\u00celes)\"  class=\"choice-106 depth-1\"  >Aland (\u00celes)<\/option><option value=\"\u00celes Ca\u00efmans\"  class=\"choice-107 depth-1\"  >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos (Keeling)\"  class=\"choice-108 depth-1\"  >\u00celes Cocos (Keeling)<\/option><option value=\"\u00celes Cook\"  class=\"choice-109 depth-1\"  >\u00celes Cook<\/option><option value=\"\u00celes Malouines (Malvinas)\"  class=\"choice-110 depth-1\"  >\u00celes Malouines (Malvinas)<\/option><option value=\"\u00celes F\u00e9ro\u00e9\"  class=\"choice-111 depth-1\"  >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Heard et McDonald\"  class=\"choice-112 depth-1\"  >\u00celes Heard et McDonald<\/option><option value=\"Mariannes du Nord (\u00celes)\"  class=\"choice-113 depth-1\"  >Mariannes du Nord (\u00celes)<\/option><option value=\"\u00celes Marshall\"  class=\"choice-114 depth-1\"  >\u00celes Marshall<\/option><option value=\"\u00celes Norfolk\"  class=\"choice-115 depth-1\"  >\u00celes Norfolk<\/option><option value=\"Saint-Pierre et Miquelon (\u00celes)\"  class=\"choice-116 depth-1\"  >Saint-Pierre et Miquelon (\u00celes)<\/option><option value=\"\u00celes Salomon\"  class=\"choice-117 depth-1\"  >\u00celes Salomon<\/option><option value=\"Svalbard et \u00eeles Jan Mayen\"  class=\"choice-118 depth-1\"  >Svalbard et \u00eeles Jan Mayen<\/option><option value=\"\u00celes Turks et Caicos\"  class=\"choice-119 depth-1\"  >\u00celes Turks et Caicos<\/option><option value=\"\u00celes Vierges (US)\"  class=\"choice-120 depth-1\"  >\u00celes Vierges (US)<\/option><option value=\"\u00celes Vierges (britanniques)\"  class=\"choice-121 depth-1\"  >\u00celes Vierges (britanniques)<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\"  class=\"choice-122 depth-1\"  >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value=\"Isra\u00ebl\"  class=\"choice-123 depth-1\"  >Isra\u00ebl<\/option><option value=\"Italie\"  class=\"choice-124 depth-1\"  >Italie<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kirghizistan\"  class=\"choice-127 depth-1\"  >Kirghizistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)\"  class=\"choice-129 depth-1\"  >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value=\"Cor\u00e9e (R\u00e9publique de)\"  class=\"choice-130 depth-1\"  >Cor\u00e9e (R\u00e9publique de)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kowe\u00eft\"  class=\"choice-132 depth-1\"  >Kowe\u00eft<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettonie\"  class=\"choice-134 depth-1\"  >Lettonie<\/option><option value=\"Liban\"  class=\"choice-135 depth-1\"  >Liban<\/option><option value=\"Lib\u00e9ria\"  class=\"choice-136 depth-1\"  >Lib\u00e9ria<\/option><option value=\"Libye\"  class=\"choice-137 depth-1\"  >Libye<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lituanie\"  class=\"choice-139 depth-1\"  >Lituanie<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Mac\u00e9doine du Nord (R\u00e9publique de)\"  class=\"choice-142 depth-1\"  >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaisie\"  class=\"choice-147 depth-1\"  >Malaisie<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malte\"  class=\"choice-149 depth-1\"  >Malte<\/option><option value=\"Maroc\"  class=\"choice-150 depth-1\"  >Maroc<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritanie\"  class=\"choice-152 depth-1\"  >Mauritanie<\/option><option value=\"Maurice\"  class=\"choice-153 depth-1\"  >Maurice<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexique\"  class=\"choice-155 depth-1\"  >Mexique<\/option><option value=\"Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)\"  class=\"choice-156 depth-1\"  >Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)<\/option><option value=\"Moldavie (R\u00e9publique de)\"  class=\"choice-157 depth-1\"  >Moldavie (R\u00e9publique de)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolie\"  class=\"choice-159 depth-1\"  >Mongolie<\/option><option value=\"Mont\u00e9n\u00e9gro\"  class=\"choice-160 depth-1\"  >Mont\u00e9n\u00e9gro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibie\"  class=\"choice-163 depth-1\"  >Namibie<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"N\u00e9pal\"  class=\"choice-165 depth-1\"  >N\u00e9pal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nig\u00e9ria\"  class=\"choice-168 depth-1\"  >Nig\u00e9ria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norv\u00e8ge\"  class=\"choice-170 depth-1\"  >Norv\u00e8ge<\/option><option value=\"Nouvelle-Cal\u00e9donie\"  class=\"choice-171 depth-1\"  >Nouvelle-Cal\u00e9donie<\/option><option value=\"Nouvelle-Z\u00e9lande\"  class=\"choice-172 depth-1\"  >Nouvelle-Z\u00e9lande<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Les Pays-Bas\"  class=\"choice-174 depth-1\"  >Les Pays-Bas<\/option><option value=\"Pakistan\"  class=\"choice-175 depth-1\"  >Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (\u00c9tat de)\"  class=\"choice-177 depth-1\"  >Palestine (\u00c9tat de)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\"  class=\"choice-179 depth-1\"  >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"P\u00e9rou\"  class=\"choice-181 depth-1\"  >P\u00e9rou<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Pologne\"  class=\"choice-183 depth-1\"  >Pologne<\/option><option value=\"Polyn\u00e9sie fran\u00e7aise\"  class=\"choice-184 depth-1\"  >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"Porto Rico\"  class=\"choice-185 depth-1\"  >Porto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"Royaume-Uni de Grande-Bretagne et d&#039;Irlande du Nord\"  class=\"choice-188 depth-1\"  >Royaume-Uni de Grande-Bretagne et d'Irlande du Nord<\/option><option value=\"R\u00e9publique arabe de Syrie\"  class=\"choice-189 depth-1\"  >R\u00e9publique arabe de Syrie<\/option><option value=\"R\u00e9publique tch\u00e8que\"  class=\"choice-190 depth-1\"  >R\u00e9publique tch\u00e8que<\/option><option value=\"R\u00e9publique centrafricaine\"  class=\"choice-191 depth-1\"  >R\u00e9publique centrafricaine<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire lao\"  class=\"choice-192 depth-1\"  >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value=\"R\u00e9publique dominicaine\"  class=\"choice-193 depth-1\"  >R\u00e9publique dominicaine<\/option><option value=\"R\u00e9union (\u00cele de)\"  class=\"choice-194 depth-1\"  >R\u00e9union (\u00cele de)<\/option><option value=\"Roumanie\"  class=\"choice-195 depth-1\"  >Roumanie<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Sahara occidental\"  class=\"choice-197 depth-1\"  >Sahara occidental<\/option><option value=\"Saint-Kitts-et-Nevis\"  class=\"choice-198 depth-1\"  >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Vincent-et-les-Grenadines\"  class=\"choice-199 depth-1\"  >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Saint-Martin (partie fran\u00e7aise)\"  class=\"choice-200 depth-1\"  >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\"  class=\"choice-202 depth-1\"  >Samoa am\u00e9ricaines<\/option><option value=\"Saint-Marin\"  class=\"choice-203 depth-1\"  >Saint-Marin<\/option><option value=\"Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha\"  class=\"choice-204 depth-1\"  >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"Sainte-Lucie\"  class=\"choice-205 depth-1\"  >Sainte-Lucie<\/option><option value=\"Sao Tom\u00e9 et Principe\"  class=\"choice-206 depth-1\"  >Sao Tom\u00e9 et Principe<\/option><option value=\"S\u00e9n\u00e9gal\"  class=\"choice-207 depth-1\"  >S\u00e9n\u00e9gal<\/option><option value=\"Serbie\"  class=\"choice-208 depth-1\"  >Serbie<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapour\"  class=\"choice-211 depth-1\"  >Singapour<\/option><option value=\"Sint Maarten (partie des Pays-Bas)\"  class=\"choice-212 depth-1\"  >Sint Maarten (partie des Pays-Bas)<\/option><option value=\"Slovaquie\"  class=\"choice-213 depth-1\"  >Slovaquie<\/option><option value=\"Slov\u00e9nie\"  class=\"choice-214 depth-1\"  >Slov\u00e9nie<\/option><option value=\"Somalie\"  class=\"choice-215 depth-1\"  >Somalie<\/option><option value=\"Espagne\"  class=\"choice-216 depth-1\"  >Espagne<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"\u00c9tats-Unis d&#039;Am\u00e9rique\"  class=\"choice-218 depth-1\"  >\u00c9tats-Unis d'Am\u00e9rique<\/option><option value=\"\u00c9tat de la Cit\u00e9 du Vatican\"  class=\"choice-219 depth-1\"  >\u00c9tat de la Cit\u00e9 du Vatican<\/option><option value=\"Afrique du Sud\"  class=\"choice-220 depth-1\"  >Afrique du Sud<\/option><option value=\"Soudan\"  class=\"choice-221 depth-1\"  >Soudan<\/option><option value=\"Sud Soudan\"  class=\"choice-222 depth-1\"  >Sud Soudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Su\u00e8de\"  class=\"choice-224 depth-1\"  >Su\u00e8de<\/option><option value=\"Suisse\"  selected='selected' class=\"choice-225 depth-1\"  >Suisse<\/option><option value=\"Tadjikistan\"  class=\"choice-226 depth-1\"  >Tadjikistan<\/option><option value=\"Ta\u00efwan, R\u00e9publique de Chine\"  class=\"choice-227 depth-1\"  >Ta\u00efwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie (R\u00e9publique-Unie de)\"  class=\"choice-228 depth-1\"  >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"Les Terres australes fran\u00e7aises\"  class=\"choice-229 depth-1\"  >Les Terres australes fran\u00e7aises<\/option><option value=\"Territoire britannique dans l&#039;oc\u00e9an Indien\"  class=\"choice-230 depth-1\"  >Territoire britannique dans l'oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\"  class=\"choice-231 depth-1\"  >Tha\u00eflande<\/option><option value=\"Timor oriental\"  class=\"choice-232 depth-1\"  >Timor oriental<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinit\u00e9-et-Tobago\"  class=\"choice-236 depth-1\"  >Trinit\u00e9-et-Tobago<\/option><option value=\"Tunisie\"  class=\"choice-237 depth-1\"  >Tunisie<\/option><option value=\"Turquie\"  class=\"choice-238 depth-1\"  >Turquie<\/option><option value=\"Turkm\u00e9nistan\"  class=\"choice-239 depth-1\"  >Turkm\u00e9nistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Ouganda\"  class=\"choice-242 depth-1\"  >Ouganda<\/option><option value=\"Hongrie\"  class=\"choice-243 depth-1\"  >Hongrie<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Ouzb\u00e9kistan\"  class=\"choice-245 depth-1\"  >Ouzb\u00e9kistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (R\u00e9publique bolivarienne du)\"  class=\"choice-247 depth-1\"  >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis et Futuna\"  class=\"choice-249 depth-1\"  >Wallis et Futuna<\/option><option value=\"Y\u00e9men\"  class=\"choice-250 depth-1\"  >Y\u00e9men<\/option><option value=\"Zambie\"  class=\"choice-251 depth-1\"  >Zambie<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Royaume de)\"  class=\"choice-253 depth-1\"  >eSwatini (Royaume de)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_17-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"17\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_17\">Adresse de contact<\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_17\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][17][address1]\" placeholder=\"Adresse\" ><label for=\"wpforms-58-field_17\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_17-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][17][city]\" placeholder=\"Villes\" ><label for=\"wpforms-58-field_17-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_17-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][17][state]\" placeholder=\"Canton\" ><label for=\"wpforms-58-field_17-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_18-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"18\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_18\">T\u00e9l\u00e9phone<\/label><input type=\"tel\" id=\"wpforms-58-field_18\" class=\"wpforms-field-large\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][18]\" placeholder=\"T\u00e9l\u00e9phone\" aria-label=\"T\u00e9l\u00e9phone\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_19-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"19\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_19\">Courriel<\/label><input type=\"email\" id=\"wpforms-58-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" placeholder=\"Courriel\" spellcheck=\"false\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_83-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"83\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tMotif du contact\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_84-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"84\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_84\">Diagnostic principal<\/label><input type=\"text\" id=\"wpforms-58-field_84\" class=\"wpforms-field-large\" name=\"wpforms[fields][84]\" placeholder=\"Diagnostic principal sp\u00e9cifique\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_87-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_87\">Diagnostics secondaires sp\u00e9cifiques  <\/label><input type=\"text\" id=\"wpforms-58-field_87\" class=\"wpforms-field-large\" name=\"wpforms[fields][87]\" placeholder=\"Diagnostics secondaires fondamentaux\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_85-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\">Services requis<\/label><ul id=\"wpforms-58-field_85\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_1\" name=\"wpforms[fields][85][]\" value=\"Services de soins de base\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_1\">Services de soins de base<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_2\" name=\"wpforms[fields][85][]\" value=\"Services de soins infirmiers\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_2\">Services de soins infirmiers<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_4\" name=\"wpforms[fields][85][]\" value=\"Services de soins infirmiers sp\u00e9cialis\u00e9s\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_4\">Services de soins infirmiers sp\u00e9cialis\u00e9s<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_7\" name=\"wpforms[fields][85][]\" value=\"Services priv\u00e9s\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_7\">Services priv\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_6\" name=\"wpforms[fields][85][]\" value=\"Performances internationales\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_6\">Performances internationales<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_9\" name=\"wpforms[fields][85][]\" value=\"Service de t\u00e9l\u00e9m\u00e9decine\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_9\">Service de t\u00e9l\u00e9m\u00e9decine<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_85_8\" name=\"wpforms[fields][85][]\" value=\"Service de t\u00e9l\u00e9assistance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_85_8\">Service de t\u00e9l\u00e9assistance<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_88-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"88\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_88\">Nombre d&#039;interventions n\u00e9cessaires<\/label><input type=\"text\" id=\"wpforms-58-field_88\" class=\"wpforms-field-large\" name=\"wpforms[fields][88]\" placeholder=\"Quantit\u00e9 sp\u00e9cifique d&#039;interventions\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_86-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"86\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_86\">Demande de prise en charge<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_86\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][86][date]\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_24-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDegr\u00e9 de priorit\u00e9\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">degr\u00e9 de priorit\u00e9 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_30\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_1\" name=\"wpforms[fields][30]\" value=\"Faible\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_1\">Faible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_2\" name=\"wpforms[fields][30]\" value=\"Moyen\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_2\">Moyen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_3\" name=\"wpforms[fields][30]\" value=\"Haut\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_3\">Haut<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_30_4\" name=\"wpforms[fields][30]\" value=\"Demande d&#039;informations d\u00e9taill\u00e9es sur le service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_30_4\">Demande d'informations d\u00e9taill\u00e9es sur le service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_28-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_28\">Texte additionnel - degr\u00e9 de priorit\u00e9<\/label><textarea id=\"wpforms-58-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" placeholder=\"Texte suppl\u00e9mentaire\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_37-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tVeuillez remplir les champs suivants :\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_38\">Nom de la structure du demandeur <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_38\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][38]\" placeholder=\"Indiquez le nom de l&#039;\u00e9tablissement demandeur\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_39-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_39\">Personne de contact de l&#039;\u00e9tablissement demandeur et fonction respective <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_39\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][39]\" placeholder=\"Saisissez le nom du contact\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_104-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"104\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_104\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_104\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][104]\" placeholder=\"Saisissez une adresse\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_41-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDonn\u00e9es sur les patients\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_42-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"42\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_42\">pr\u00e9nom nom <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_42\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][42]\" placeholder=\"Nom et pr\u00e9nom\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_43-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_43\">Date de naissance <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_43\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][43][date]\" placeholder=\"Date de naissance\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_108-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"108\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_108\">Pays Patient<\/label><select id=\"wpforms-58-field_108\" class=\"wpforms-field-large\" name=\"wpforms[fields][108]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanie\"  class=\"choice-5 depth-1\"  >Albanie<\/option><option value=\"Alg\u00e9rie\"  class=\"choice-6 depth-1\"  >Alg\u00e9rie<\/option><option value=\"Andorre\"  class=\"choice-7 depth-1\"  >Andorre<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarctique\"  class=\"choice-10 depth-1\"  >Antarctique<\/option><option value=\"Antigua et Barbuda\"  class=\"choice-11 depth-1\"  >Antigua et Barbuda<\/option><option value=\"Arabie Saoudite\"  class=\"choice-12 depth-1\"  >Arabie Saoudite<\/option><option value=\"Argentine\"  class=\"choice-13 depth-1\"  >Argentine<\/option><option value=\"Arm\u00e9nie\"  class=\"choice-14 depth-1\"  >Arm\u00e9nie<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australie\"  class=\"choice-16 depth-1\"  >Australie<\/option><option value=\"Autriche\"  class=\"choice-17 depth-1\"  >Autriche<\/option><option value=\"Azerba\u00efdjan\"  class=\"choice-18 depth-1\"  >Azerba\u00efdjan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahre\u00efn\"  class=\"choice-20 depth-1\"  >Bahre\u00efn<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbade\"  class=\"choice-22 depth-1\"  >Barbade<\/option><option value=\"Belgique\"  class=\"choice-23 depth-1\"  >Belgique<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"B\u00e9nin\"  class=\"choice-25 depth-1\"  >B\u00e9nin<\/option><option value=\"Bermudes\"  class=\"choice-26 depth-1\"  >Bermudes<\/option><option value=\"Bhoutan\"  class=\"choice-27 depth-1\"  >Bhoutan<\/option><option value=\"B\u00e9larus\"  class=\"choice-28 depth-1\"  >B\u00e9larus<\/option><option value=\"Birmanie\"  class=\"choice-29 depth-1\"  >Birmanie<\/option><option value=\"Bolivie (\u00c9tat plurinational de)\"  class=\"choice-30 depth-1\"  >Bolivie (\u00c9tat plurinational de)<\/option><option value=\"Bonaire, Saint-Eustache et Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint-Eustache et Saba<\/option><option value=\"Bosnie et Herz\u00e9govine\"  class=\"choice-32 depth-1\"  >Bosnie et Herz\u00e9govine<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Br\u00e9sil\"  class=\"choice-34 depth-1\"  >Br\u00e9sil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarie\"  class=\"choice-36 depth-1\"  >Bulgarie<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodge\"  class=\"choice-39 depth-1\"  >Cambodge<\/option><option value=\"Cameroun\"  class=\"choice-40 depth-1\"  >Cameroun<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cap Vert\"  class=\"choice-42 depth-1\"  >Cap Vert<\/option><option value=\"Tchad\"  class=\"choice-43 depth-1\"  >Tchad<\/option><option value=\"Chili\"  class=\"choice-44 depth-1\"  >Chili<\/option><option value=\"Chine\"  class=\"choice-45 depth-1\"  >Chine<\/option><option value=\"Chypre\"  class=\"choice-46 depth-1\"  >Chypre<\/option><option value=\"Colombie\"  class=\"choice-47 depth-1\"  >Colombie<\/option><option value=\"Comores\"  class=\"choice-48 depth-1\"  >Comores<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (R\u00e9publique d\u00e9mocratique du)\"  class=\"choice-50 depth-1\"  >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\"  class=\"choice-52 depth-1\"  >C\u00f4te d'Ivoire<\/option><option value=\"Croatie\"  class=\"choice-53 depth-1\"  >Croatie<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Danemark\"  class=\"choice-56 depth-1\"  >Danemark<\/option><option value=\"Dominique\"  class=\"choice-57 depth-1\"  >Dominique<\/option><option value=\"\u00c9quateur\"  class=\"choice-58 depth-1\"  >\u00c9quateur<\/option><option value=\"\u00c9gypte\"  class=\"choice-59 depth-1\"  >\u00c9gypte<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"\u00c9mirats arabes unis\"  class=\"choice-61 depth-1\"  >\u00c9mirats arabes unis<\/option><option value=\"Erythr\u00e9e\"  class=\"choice-62 depth-1\"  >Erythr\u00e9e<\/option><option value=\"Estonie\"  class=\"choice-63 depth-1\"  >Estonie<\/option><option value=\"\u00c9thiopie\"  class=\"choice-64 depth-1\"  >\u00c9thiopie<\/option><option value=\"F\u00e9d\u00e9ration de Russie\"  class=\"choice-65 depth-1\"  >F\u00e9d\u00e9ration de Russie<\/option><option value=\"Fidji\"  class=\"choice-66 depth-1\"  >Fidji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finlande\"  class=\"choice-68 depth-1\"  >Finlande<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambie\"  class=\"choice-71 depth-1\"  >Gambie<\/option><option value=\"G\u00e9orgie\"  class=\"choice-72 depth-1\"  >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et \u00eeles Sandwich du Sud\"  class=\"choice-73 depth-1\"  >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"Allemagne\"  class=\"choice-74 depth-1\"  >Allemagne<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jama\u00efque\"  class=\"choice-76 depth-1\"  >Jama\u00efque<\/option><option value=\"Japon\"  class=\"choice-77 depth-1\"  >Japon<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordanie\"  class=\"choice-80 depth-1\"  >Jordanie<\/option><option value=\"Gr\u00e8ce\"  class=\"choice-81 depth-1\"  >Gr\u00e8ce<\/option><option value=\"Grenade\"  class=\"choice-82 depth-1\"  >Grenade<\/option><option value=\"Groenland\"  class=\"choice-83 depth-1\"  >Groenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernesey\"  class=\"choice-87 depth-1\"  >Guernesey<\/option><option value=\"Guyane fran\u00e7aise\"  class=\"choice-88 depth-1\"  >Guyane fran\u00e7aise<\/option><option value=\"Guin\u00e9e\"  class=\"choice-89 depth-1\"  >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00e9quatoriale\"  class=\"choice-90 depth-1\"  >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\"  class=\"choice-91 depth-1\"  >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\"  class=\"choice-92 depth-1\"  >Guyane<\/option><option value=\"Ha\u00efti\"  class=\"choice-93 depth-1\"  >Ha\u00efti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"Inde\"  class=\"choice-96 depth-1\"  >Inde<\/option><option value=\"Indon\u00e9sie\"  class=\"choice-97 depth-1\"  >Indon\u00e9sie<\/option><option value=\"Iran (R\u00e9publique islamique d&#039;)\"  class=\"choice-98 depth-1\"  >Iran (R\u00e9publique islamique d')<\/option><option value=\"L&#039;Irak\"  class=\"choice-99 depth-1\"  >L'Irak<\/option><option value=\"Irlande (R\u00e9publique d&#039;)\"  class=\"choice-100 depth-1\"  >Irlande (R\u00e9publique d')<\/option><option value=\"Islande\"  class=\"choice-101 depth-1\"  >Islande<\/option><option value=\"\u00cele Bouvet\"  class=\"choice-102 depth-1\"  >\u00cele Bouvet<\/option><option value=\"\u00cele de Man\"  class=\"choice-103 depth-1\"  >\u00cele de Man<\/option><option value=\"L&#039;\u00eele de No\u00ebl\"  class=\"choice-104 depth-1\"  >L'\u00eele de No\u00ebl<\/option><option value=\"\u00cele de Saint-Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >\u00cele de Saint-Barth\u00e9lemy<\/option><option value=\"Aland (\u00celes)\"  class=\"choice-106 depth-1\"  >Aland (\u00celes)<\/option><option value=\"\u00celes Ca\u00efmans\"  class=\"choice-107 depth-1\"  >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos (Keeling)\"  class=\"choice-108 depth-1\"  >\u00celes Cocos (Keeling)<\/option><option value=\"\u00celes Cook\"  class=\"choice-109 depth-1\"  >\u00celes Cook<\/option><option value=\"\u00celes Malouines (Malvinas)\"  class=\"choice-110 depth-1\"  >\u00celes Malouines (Malvinas)<\/option><option value=\"\u00celes F\u00e9ro\u00e9\"  class=\"choice-111 depth-1\"  >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Heard et McDonald\"  class=\"choice-112 depth-1\"  >\u00celes Heard et McDonald<\/option><option value=\"Mariannes du Nord (\u00celes)\"  class=\"choice-113 depth-1\"  >Mariannes du Nord (\u00celes)<\/option><option value=\"\u00celes Marshall\"  class=\"choice-114 depth-1\"  >\u00celes Marshall<\/option><option value=\"\u00celes Norfolk\"  class=\"choice-115 depth-1\"  >\u00celes Norfolk<\/option><option value=\"Saint-Pierre et Miquelon (\u00celes)\"  class=\"choice-116 depth-1\"  >Saint-Pierre et Miquelon (\u00celes)<\/option><option value=\"\u00celes Salomon\"  class=\"choice-117 depth-1\"  >\u00celes Salomon<\/option><option value=\"Svalbard et \u00eeles Jan Mayen\"  class=\"choice-118 depth-1\"  >Svalbard et \u00eeles Jan Mayen<\/option><option value=\"\u00celes Turks et Caicos\"  class=\"choice-119 depth-1\"  >\u00celes Turks et Caicos<\/option><option value=\"\u00celes Vierges (US)\"  class=\"choice-120 depth-1\"  >\u00celes Vierges (US)<\/option><option value=\"\u00celes Vierges (britanniques)\"  class=\"choice-121 depth-1\"  >\u00celes Vierges (britanniques)<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\"  class=\"choice-122 depth-1\"  >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value=\"Isra\u00ebl\"  class=\"choice-123 depth-1\"  >Isra\u00ebl<\/option><option value=\"Italie\"  class=\"choice-124 depth-1\"  >Italie<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kirghizistan\"  class=\"choice-127 depth-1\"  >Kirghizistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)\"  class=\"choice-129 depth-1\"  >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value=\"Cor\u00e9e (R\u00e9publique de)\"  class=\"choice-130 depth-1\"  >Cor\u00e9e (R\u00e9publique de)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kowe\u00eft\"  class=\"choice-132 depth-1\"  >Kowe\u00eft<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettonie\"  class=\"choice-134 depth-1\"  >Lettonie<\/option><option value=\"Liban\"  class=\"choice-135 depth-1\"  >Liban<\/option><option value=\"Lib\u00e9ria\"  class=\"choice-136 depth-1\"  >Lib\u00e9ria<\/option><option value=\"Libye\"  class=\"choice-137 depth-1\"  >Libye<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lituanie\"  class=\"choice-139 depth-1\"  >Lituanie<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Mac\u00e9doine du Nord (R\u00e9publique de)\"  class=\"choice-142 depth-1\"  >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaisie\"  class=\"choice-147 depth-1\"  >Malaisie<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malte\"  class=\"choice-149 depth-1\"  >Malte<\/option><option value=\"Maroc\"  class=\"choice-150 depth-1\"  >Maroc<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritanie\"  class=\"choice-152 depth-1\"  >Mauritanie<\/option><option value=\"Maurice\"  class=\"choice-153 depth-1\"  >Maurice<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexique\"  class=\"choice-155 depth-1\"  >Mexique<\/option><option value=\"Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)\"  class=\"choice-156 depth-1\"  >Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)<\/option><option value=\"Moldavie (R\u00e9publique de)\"  class=\"choice-157 depth-1\"  >Moldavie (R\u00e9publique de)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolie\"  class=\"choice-159 depth-1\"  >Mongolie<\/option><option value=\"Mont\u00e9n\u00e9gro\"  class=\"choice-160 depth-1\"  >Mont\u00e9n\u00e9gro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibie\"  class=\"choice-163 depth-1\"  >Namibie<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"N\u00e9pal\"  class=\"choice-165 depth-1\"  >N\u00e9pal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nig\u00e9ria\"  class=\"choice-168 depth-1\"  >Nig\u00e9ria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norv\u00e8ge\"  class=\"choice-170 depth-1\"  >Norv\u00e8ge<\/option><option value=\"Nouvelle-Cal\u00e9donie\"  class=\"choice-171 depth-1\"  >Nouvelle-Cal\u00e9donie<\/option><option value=\"Nouvelle-Z\u00e9lande\"  class=\"choice-172 depth-1\"  >Nouvelle-Z\u00e9lande<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Les Pays-Bas\"  class=\"choice-174 depth-1\"  >Les Pays-Bas<\/option><option value=\"Le Pakistan\"  class=\"choice-175 depth-1\"  >Le Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (\u00c9tat de)\"  class=\"choice-177 depth-1\"  >Palestine (\u00c9tat de)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\"  class=\"choice-179 depth-1\"  >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"P\u00e9rou\"  class=\"choice-181 depth-1\"  >P\u00e9rou<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Pologne\"  class=\"choice-183 depth-1\"  >Pologne<\/option><option value=\"Polyn\u00e9sie fran\u00e7aise\"  class=\"choice-184 depth-1\"  >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"Porto Rico\"  class=\"choice-185 depth-1\"  >Porto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"Royaume-Uni de Grande-Bretagne et d&#039;Irlande du Nord\"  class=\"choice-188 depth-1\"  >Royaume-Uni de Grande-Bretagne et d'Irlande du Nord<\/option><option value=\"R\u00e9publique arabe de Syrie\"  class=\"choice-189 depth-1\"  >R\u00e9publique arabe de Syrie<\/option><option value=\"R\u00e9publique tch\u00e8que\"  class=\"choice-190 depth-1\"  >R\u00e9publique tch\u00e8que<\/option><option value=\"R\u00e9publique centrafricaine\"  class=\"choice-191 depth-1\"  >R\u00e9publique centrafricaine<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire lao\"  class=\"choice-192 depth-1\"  >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value=\"R\u00e9publique dominicaine\"  class=\"choice-193 depth-1\"  >R\u00e9publique dominicaine<\/option><option value=\"R\u00e9union (\u00cele de)\"  class=\"choice-194 depth-1\"  >R\u00e9union (\u00cele de)<\/option><option value=\"Roumanie\"  class=\"choice-195 depth-1\"  >Roumanie<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Sahara occidental\"  class=\"choice-197 depth-1\"  >Sahara occidental<\/option><option value=\"Saint-Kitts-et-Nevis\"  class=\"choice-198 depth-1\"  >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Vincent-et-les-Grenadines\"  class=\"choice-199 depth-1\"  >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Saint-Martin (partie fran\u00e7aise)\"  class=\"choice-200 depth-1\"  >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\"  class=\"choice-202 depth-1\"  >Samoa am\u00e9ricaines<\/option><option value=\"Saint-Marin\"  class=\"choice-203 depth-1\"  >Saint-Marin<\/option><option value=\"Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha\"  class=\"choice-204 depth-1\"  >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"Sainte-Lucie\"  class=\"choice-205 depth-1\"  >Sainte-Lucie<\/option><option value=\"Sao Tom\u00e9 et Principe\"  class=\"choice-206 depth-1\"  >Sao Tom\u00e9 et Principe<\/option><option value=\"S\u00e9n\u00e9gal\"  class=\"choice-207 depth-1\"  >S\u00e9n\u00e9gal<\/option><option value=\"Serbie\"  class=\"choice-208 depth-1\"  >Serbie<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapour\"  class=\"choice-211 depth-1\"  >Singapour<\/option><option value=\"Sint Maarten (partie des Pays-Bas)\"  class=\"choice-212 depth-1\"  >Sint Maarten (partie des Pays-Bas)<\/option><option value=\"Slovaquie\"  class=\"choice-213 depth-1\"  >Slovaquie<\/option><option value=\"Slov\u00e9nie\"  class=\"choice-214 depth-1\"  >Slov\u00e9nie<\/option><option value=\"Somalie\"  class=\"choice-215 depth-1\"  >Somalie<\/option><option value=\"Espagne\"  class=\"choice-216 depth-1\"  >Espagne<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"\u00c9tats-Unis d&#039;Am\u00e9rique\"  class=\"choice-218 depth-1\"  >\u00c9tats-Unis d'Am\u00e9rique<\/option><option value=\"\u00c9tat de la Cit\u00e9 du Vatican\"  class=\"choice-219 depth-1\"  >\u00c9tat de la Cit\u00e9 du Vatican<\/option><option value=\"Afrique du Sud\"  class=\"choice-220 depth-1\"  >Afrique du Sud<\/option><option value=\"Soudan\"  class=\"choice-221 depth-1\"  >Soudan<\/option><option value=\"Sud Soudan\"  class=\"choice-222 depth-1\"  >Sud Soudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Su\u00e8de\"  class=\"choice-224 depth-1\"  >Su\u00e8de<\/option><option value=\"Suisse\"  selected='selected' class=\"choice-225 depth-1\"  >Suisse<\/option><option value=\"Tadjikistan\"  class=\"choice-226 depth-1\"  >Tadjikistan<\/option><option value=\"Ta\u00efwan, R\u00e9publique de Chine\"  class=\"choice-227 depth-1\"  >Ta\u00efwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie (R\u00e9publique-Unie de)\"  class=\"choice-228 depth-1\"  >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"Les Terres australes fran\u00e7aises\"  class=\"choice-229 depth-1\"  >Les Terres australes fran\u00e7aises<\/option><option value=\"Territoire britannique dans l&#039;oc\u00e9an Indien\"  class=\"choice-230 depth-1\"  >Territoire britannique dans l'oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\"  class=\"choice-231 depth-1\"  >Tha\u00eflande<\/option><option value=\"Timor oriental\"  class=\"choice-232 depth-1\"  >Timor oriental<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinit\u00e9-et-Tobago\"  class=\"choice-236 depth-1\"  >Trinit\u00e9-et-Tobago<\/option><option value=\"Tunisie\"  class=\"choice-237 depth-1\"  >Tunisie<\/option><option value=\"Turquie\"  class=\"choice-238 depth-1\"  >Turquie<\/option><option value=\"Turkm\u00e9nistan\"  class=\"choice-239 depth-1\"  >Turkm\u00e9nistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Ouganda\"  class=\"choice-242 depth-1\"  >Ouganda<\/option><option value=\"Hongrie\"  class=\"choice-243 depth-1\"  >Hongrie<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Ouzb\u00e9kistan\"  class=\"choice-245 depth-1\"  >Ouzb\u00e9kistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (R\u00e9publique bolivarienne du)\"  class=\"choice-247 depth-1\"  >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis et Futuna\"  class=\"choice-249 depth-1\"  >Wallis et Futuna<\/option><option value=\"Y\u00e9men\"  class=\"choice-250 depth-1\"  >Y\u00e9men<\/option><option value=\"Zambie\"  class=\"choice-251 depth-1\"  >Zambie<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Royaume de)\"  class=\"choice-253 depth-1\"  >eSwatini (Royaume de)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_44-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_44\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_44\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][44][address1]\" placeholder=\"Adresse\" required><label for=\"wpforms-58-field_44\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_44-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][44][city]\" placeholder=\"Villes\" required><label for=\"wpforms-58-field_44-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_44-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][44][state]\" placeholder=\"Canton\" required><label for=\"wpforms-58-field_44-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_45-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_45\">T\u00e9l\u00e9phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_45\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][45]\" placeholder=\"T\u00e9l\u00e9phone\" aria-label=\"T\u00e9l\u00e9phone\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_46-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_46\">Courriel<\/label><input type=\"email\" id=\"wpforms-58-field_46\" class=\"wpforms-field-large\" name=\"wpforms[fields][46]\" placeholder=\"Courriel\" spellcheck=\"false\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_48\">M\u00e9decin traitant <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_48\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][48]\" placeholder=\"M\u00e9decin traitant\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_95-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"95\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_96-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_96\">Compagnie d&#039;assurance<\/label><input type=\"text\" id=\"wpforms-58-field_96\" class=\"wpforms-field-large\" name=\"wpforms[fields][96]\" placeholder=\"Compagnie d&#039;assurance\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_97-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_97\">AVS<\/label><input type=\"text\" id=\"wpforms-58-field_97\" class=\"wpforms-field-large\" name=\"wpforms[fields][97]\" placeholder=\"AVS\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_49-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_49\">Num\u00e9ro d&#039;assur\u00e9<\/label><input type=\"text\" id=\"wpforms-58-field_49\" class=\"wpforms-field-large\" name=\"wpforms[fields][49]\" placeholder=\"Num\u00e9ro d&#039;assur\u00e9\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_89-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"89\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tMotif du contact\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_90-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"90\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_90\">Diagnostic principal <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_90\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][90]\" placeholder=\"Diagnostic principal sp\u00e9cifique\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_93-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"93\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_93\">Diagnostics secondaires sp\u00e9cifiques  <\/label><input type=\"text\" id=\"wpforms-58-field_93\" class=\"wpforms-field-large\" name=\"wpforms[fields][93]\" placeholder=\"Diagnostics secondaires fondamentaux\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_91-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"91\" style=\"display:none;\"><label class=\"wpforms-field-label\">Services requis <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_91\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_1\" name=\"wpforms[fields][91][]\" value=\"Services de soins de base\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_1\">Services de soins de base<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_2\" name=\"wpforms[fields][91][]\" value=\"Services de soins infirmiers\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_2\">Services de soins infirmiers<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_4\" name=\"wpforms[fields][91][]\" value=\"Services de soins infirmiers sp\u00e9cialis\u00e9s\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_4\">Services de soins infirmiers sp\u00e9cialis\u00e9s<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_7\" name=\"wpforms[fields][91][]\" value=\"Services priv\u00e9s\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_7\">Services priv\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_6\" name=\"wpforms[fields][91][]\" value=\"Performances internationales\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_6\">Performances internationales<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_9\" name=\"wpforms[fields][91][]\" value=\"Service de t\u00e9l\u00e9m\u00e9decine\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_9\">Service de t\u00e9l\u00e9m\u00e9decine<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_91_8\" name=\"wpforms[fields][91][]\" value=\"Service de t\u00e9l\u00e9assistance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_91_8\">Service de t\u00e9l\u00e9assistance<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_94-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"94\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_94\">Nombre d&#039;interventions n\u00e9cessaires<\/label><input type=\"text\" id=\"wpforms-58-field_94\" class=\"wpforms-field-large\" name=\"wpforms[fields][94]\" placeholder=\"Quantit\u00e9 sp\u00e9cifique d&#039;interventions\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_92-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"92\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_92\">Demande de prise en charge <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_92\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][92][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_74-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"74\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDegr\u00e9 de priorit\u00e9\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_75-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"75\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">Choix multiple <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_75\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_1\" name=\"wpforms[fields][75]\" value=\"Faible\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_1\">Faible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_2\" name=\"wpforms[fields][75]\" value=\"Moyen\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_2\">Moyen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_3\" name=\"wpforms[fields][75]\" value=\"Haut\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_3\">Haut<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_75_4\" name=\"wpforms[fields][75]\" value=\"Demande d&#039;informations d\u00e9taill\u00e9es sur le service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_75_4\">Demande d'informations d\u00e9taill\u00e9es sur le service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_76-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"76\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_76\">Texte suppl\u00e9mentaire<\/label><textarea id=\"wpforms-58-field_76\" class=\"wpforms-field-medium\" name=\"wpforms[fields][76]\" placeholder=\"Texte suppl\u00e9mentaire\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_73-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tM\u00e9decin traitant demandeur\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_66\">M\u00e9decin traitant demandeur <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_66\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][66]\" placeholder=\"Pr\u00e9cisez le nom du m\u00e9decin traitant demandeur\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_57-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"57\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDonn\u00e9es sur les patients\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"58\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_58\">pr\u00e9nom nom <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_58\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][58]\" placeholder=\"Nom et pr\u00e9nom\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_59-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_59\">Date de naissance <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_59\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][59][date]\" placeholder=\"Date de naissance\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_109-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"109\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_109\">Pays Patient<\/label><select id=\"wpforms-58-field_109\" class=\"wpforms-field-large\" name=\"wpforms[fields][109]\"><option value=\"\" class=\"placeholder\" disabled >Nation<\/option><option value=\"Afghanistan\"  class=\"choice-4 depth-1\"  >Afghanistan<\/option><option value=\"Albanie\"  class=\"choice-5 depth-1\"  >Albanie<\/option><option value=\"Alg\u00e9rie\"  class=\"choice-6 depth-1\"  >Alg\u00e9rie<\/option><option value=\"Andorre\"  class=\"choice-7 depth-1\"  >Andorre<\/option><option value=\"Angola\"  class=\"choice-8 depth-1\"  >Angola<\/option><option value=\"Anguilla\"  class=\"choice-9 depth-1\"  >Anguilla<\/option><option value=\"Antarctique\"  class=\"choice-10 depth-1\"  >Antarctique<\/option><option value=\"Antigua et Barbuda\"  class=\"choice-11 depth-1\"  >Antigua et Barbuda<\/option><option value=\"Arabie Saoudite\"  class=\"choice-12 depth-1\"  >Arabie Saoudite<\/option><option value=\"Argentine\"  class=\"choice-13 depth-1\"  >Argentine<\/option><option value=\"Arm\u00e9nie\"  class=\"choice-14 depth-1\"  >Arm\u00e9nie<\/option><option value=\"Aruba\"  class=\"choice-15 depth-1\"  >Aruba<\/option><option value=\"Australie\"  class=\"choice-16 depth-1\"  >Australie<\/option><option value=\"Autriche\"  class=\"choice-17 depth-1\"  >Autriche<\/option><option value=\"Azerba\u00efdjan\"  class=\"choice-18 depth-1\"  >Azerba\u00efdjan<\/option><option value=\"Bahamas\"  class=\"choice-19 depth-1\"  >Bahamas<\/option><option value=\"Bahre\u00efn\"  class=\"choice-20 depth-1\"  >Bahre\u00efn<\/option><option value=\"Bangladesh\"  class=\"choice-21 depth-1\"  >Bangladesh<\/option><option value=\"Barbade\"  class=\"choice-22 depth-1\"  >Barbade<\/option><option value=\"Belgique\"  class=\"choice-23 depth-1\"  >Belgique<\/option><option value=\"Belize\"  class=\"choice-24 depth-1\"  >Belize<\/option><option value=\"B\u00e9nin\"  class=\"choice-25 depth-1\"  >B\u00e9nin<\/option><option value=\"Bermudes\"  class=\"choice-26 depth-1\"  >Bermudes<\/option><option value=\"Bhoutan\"  class=\"choice-27 depth-1\"  >Bhoutan<\/option><option value=\"B\u00e9larus\"  class=\"choice-28 depth-1\"  >B\u00e9larus<\/option><option value=\"Birmanie\"  class=\"choice-29 depth-1\"  >Birmanie<\/option><option value=\"Bolivie (\u00c9tat plurinational de)\"  class=\"choice-30 depth-1\"  >Bolivie (\u00c9tat plurinational de)<\/option><option value=\"Bonaire, Saint-Eustache et Saba\"  class=\"choice-31 depth-1\"  >Bonaire, Saint-Eustache et Saba<\/option><option value=\"Bosnie et Herz\u00e9govine\"  class=\"choice-32 depth-1\"  >Bosnie et Herz\u00e9govine<\/option><option value=\"Botswana\"  class=\"choice-33 depth-1\"  >Botswana<\/option><option value=\"Br\u00e9sil\"  class=\"choice-34 depth-1\"  >Br\u00e9sil<\/option><option value=\"Brunei Darrussalam\"  class=\"choice-35 depth-1\"  >Brunei Darrussalam<\/option><option value=\"Bulgarie\"  class=\"choice-36 depth-1\"  >Bulgarie<\/option><option value=\"Burkina Faso\"  class=\"choice-37 depth-1\"  >Burkina Faso<\/option><option value=\"Burundi\"  class=\"choice-38 depth-1\"  >Burundi<\/option><option value=\"Cambodge\"  class=\"choice-39 depth-1\"  >Cambodge<\/option><option value=\"Cameroun\"  class=\"choice-40 depth-1\"  >Cameroun<\/option><option value=\"Canada\"  class=\"choice-41 depth-1\"  >Canada<\/option><option value=\"Cap Vert\"  class=\"choice-42 depth-1\"  >Cap Vert<\/option><option value=\"Tchad\"  class=\"choice-43 depth-1\"  >Tchad<\/option><option value=\"Chili\"  class=\"choice-44 depth-1\"  >Chili<\/option><option value=\"Chine\"  class=\"choice-45 depth-1\"  >Chine<\/option><option value=\"Chypre\"  class=\"choice-46 depth-1\"  >Chypre<\/option><option value=\"Colombie\"  class=\"choice-47 depth-1\"  >Colombie<\/option><option value=\"Comores\"  class=\"choice-48 depth-1\"  >Comores<\/option><option value=\"Congo\"  class=\"choice-49 depth-1\"  >Congo<\/option><option value=\"Congo (R\u00e9publique d\u00e9mocratique du)\"  class=\"choice-50 depth-1\"  >Congo (R\u00e9publique d\u00e9mocratique du)<\/option><option value=\"Costa Rica\"  class=\"choice-51 depth-1\"  >Costa Rica<\/option><option value=\"C\u00f4te d&#039;Ivoire\"  class=\"choice-52 depth-1\"  >C\u00f4te d'Ivoire<\/option><option value=\"Croatie\"  class=\"choice-53 depth-1\"  >Croatie<\/option><option value=\"Cuba\"  class=\"choice-54 depth-1\"  >Cuba<\/option><option value=\"Cura\u00e7ao\"  class=\"choice-55 depth-1\"  >Cura\u00e7ao<\/option><option value=\"Danemark\"  class=\"choice-56 depth-1\"  >Danemark<\/option><option value=\"Dominique\"  class=\"choice-57 depth-1\"  >Dominique<\/option><option value=\"\u00c9quateur\"  class=\"choice-58 depth-1\"  >\u00c9quateur<\/option><option value=\"\u00c9gypte\"  class=\"choice-59 depth-1\"  >\u00c9gypte<\/option><option value=\"El Salvador\"  class=\"choice-60 depth-1\"  >El Salvador<\/option><option value=\"\u00c9mirats arabes unis\"  class=\"choice-61 depth-1\"  >\u00c9mirats arabes unis<\/option><option value=\"Erythr\u00e9e\"  class=\"choice-62 depth-1\"  >Erythr\u00e9e<\/option><option value=\"Estonie\"  class=\"choice-63 depth-1\"  >Estonie<\/option><option value=\"\u00c9thiopie\"  class=\"choice-64 depth-1\"  >\u00c9thiopie<\/option><option value=\"F\u00e9d\u00e9ration de Russie\"  class=\"choice-65 depth-1\"  >F\u00e9d\u00e9ration de Russie<\/option><option value=\"Fidji\"  class=\"choice-66 depth-1\"  >Fidji<\/option><option value=\"Philippines\"  class=\"choice-67 depth-1\"  >Philippines<\/option><option value=\"Finlande\"  class=\"choice-68 depth-1\"  >Finlande<\/option><option value=\"France\"  class=\"choice-69 depth-1\"  >France<\/option><option value=\"Gabon\"  class=\"choice-70 depth-1\"  >Gabon<\/option><option value=\"Gambie\"  class=\"choice-71 depth-1\"  >Gambie<\/option><option value=\"G\u00e9orgie\"  class=\"choice-72 depth-1\"  >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et \u00eeles Sandwich du Sud\"  class=\"choice-73 depth-1\"  >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value=\"Allemagne\"  class=\"choice-74 depth-1\"  >Allemagne<\/option><option value=\"Ghana\"  class=\"choice-75 depth-1\"  >Ghana<\/option><option value=\"Jama\u00efque\"  class=\"choice-76 depth-1\"  >Jama\u00efque<\/option><option value=\"Japon\"  class=\"choice-77 depth-1\"  >Japon<\/option><option value=\"Gibraltar\"  class=\"choice-78 depth-1\"  >Gibraltar<\/option><option value=\"Djibouti\"  class=\"choice-79 depth-1\"  >Djibouti<\/option><option value=\"Jordanie\"  class=\"choice-80 depth-1\"  >Jordanie<\/option><option value=\"Gr\u00e8ce\"  class=\"choice-81 depth-1\"  >Gr\u00e8ce<\/option><option value=\"Grenade\"  class=\"choice-82 depth-1\"  >Grenade<\/option><option value=\"Groenland\"  class=\"choice-83 depth-1\"  >Groenland<\/option><option value=\"Guadeloupe\"  class=\"choice-84 depth-1\"  >Guadeloupe<\/option><option value=\"Guam\"  class=\"choice-85 depth-1\"  >Guam<\/option><option value=\"Guatemala\"  class=\"choice-86 depth-1\"  >Guatemala<\/option><option value=\"Guernesey\"  class=\"choice-87 depth-1\"  >Guernesey<\/option><option value=\"Guyane fran\u00e7aise\"  class=\"choice-88 depth-1\"  >Guyane fran\u00e7aise<\/option><option value=\"Guin\u00e9e\"  class=\"choice-89 depth-1\"  >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00e9quatoriale\"  class=\"choice-90 depth-1\"  >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\"  class=\"choice-91 depth-1\"  >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\"  class=\"choice-92 depth-1\"  >Guyane<\/option><option value=\"Ha\u00efti\"  class=\"choice-93 depth-1\"  >Ha\u00efti<\/option><option value=\"Honduras\"  class=\"choice-94 depth-1\"  >Honduras<\/option><option value=\"Hong Kong\"  class=\"choice-95 depth-1\"  >Hong Kong<\/option><option value=\"Inde\"  class=\"choice-96 depth-1\"  >Inde<\/option><option value=\"Indon\u00e9sie\"  class=\"choice-97 depth-1\"  >Indon\u00e9sie<\/option><option value=\"Iran (R\u00e9publique islamique d&#039;)\"  class=\"choice-98 depth-1\"  >Iran (R\u00e9publique islamique d')<\/option><option value=\"L&#039;Irak\"  class=\"choice-99 depth-1\"  >L'Irak<\/option><option value=\"Irlande (R\u00e9publique d&#039;)\"  class=\"choice-100 depth-1\"  >Irlande (R\u00e9publique d')<\/option><option value=\"Islande\"  class=\"choice-101 depth-1\"  >Islande<\/option><option value=\"\u00cele Bouvet\"  class=\"choice-102 depth-1\"  >\u00cele Bouvet<\/option><option value=\"\u00cele de Man\"  class=\"choice-103 depth-1\"  >\u00cele de Man<\/option><option value=\"L&#039;\u00eele de No\u00ebl\"  class=\"choice-104 depth-1\"  >L'\u00eele de No\u00ebl<\/option><option value=\"\u00cele de Saint-Barth\u00e9lemy\"  class=\"choice-105 depth-1\"  >\u00cele de Saint-Barth\u00e9lemy<\/option><option value=\"Aland (\u00celes)\"  class=\"choice-106 depth-1\"  >Aland (\u00celes)<\/option><option value=\"\u00celes Ca\u00efmans\"  class=\"choice-107 depth-1\"  >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos (Keeling)\"  class=\"choice-108 depth-1\"  >\u00celes Cocos (Keeling)<\/option><option value=\"\u00celes Cook\"  class=\"choice-109 depth-1\"  >\u00celes Cook<\/option><option value=\"\u00celes Malouines (Malvinas)\"  class=\"choice-110 depth-1\"  >\u00celes Malouines (Malvinas)<\/option><option value=\"\u00celes F\u00e9ro\u00e9\"  class=\"choice-111 depth-1\"  >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Heard et McDonald\"  class=\"choice-112 depth-1\"  >\u00celes Heard et McDonald<\/option><option value=\"Mariannes du Nord (\u00celes)\"  class=\"choice-113 depth-1\"  >Mariannes du Nord (\u00celes)<\/option><option value=\"\u00celes Marshall\"  class=\"choice-114 depth-1\"  >\u00celes Marshall<\/option><option value=\"\u00celes Norfolk\"  class=\"choice-115 depth-1\"  >\u00celes Norfolk<\/option><option value=\"Saint-Pierre et Miquelon (\u00celes)\"  class=\"choice-116 depth-1\"  >Saint-Pierre et Miquelon (\u00celes)<\/option><option value=\"\u00celes Salomon\"  class=\"choice-117 depth-1\"  >\u00celes Salomon<\/option><option value=\"Svalbard et \u00celes Jan Mayen\"  class=\"choice-118 depth-1\"  >Svalbard et \u00celes Jan Mayen<\/option><option value=\"\u00celes Turks et Caicos\"  class=\"choice-119 depth-1\"  >\u00celes Turks et Caicos<\/option><option value=\"\u00celes Vierges (US)\"  class=\"choice-120 depth-1\"  >\u00celes Vierges (US)<\/option><option value=\"\u00celes Vierges (britanniques)\"  class=\"choice-121 depth-1\"  >\u00celes Vierges (britanniques)<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\"  class=\"choice-122 depth-1\"  >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value=\"Isra\u00ebl\"  class=\"choice-123 depth-1\"  >Isra\u00ebl<\/option><option value=\"Italie\"  class=\"choice-124 depth-1\"  >Italie<\/option><option value=\"Kazakhstan\"  class=\"choice-125 depth-1\"  >Kazakhstan<\/option><option value=\"Kenya\"  class=\"choice-126 depth-1\"  >Kenya<\/option><option value=\"Kirghizistan\"  class=\"choice-127 depth-1\"  >Kirghizistan<\/option><option value=\"Kiribati\"  class=\"choice-128 depth-1\"  >Kiribati<\/option><option value=\"Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)\"  class=\"choice-129 depth-1\"  >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value=\"Cor\u00e9e (R\u00e9publique de)\"  class=\"choice-130 depth-1\"  >Cor\u00e9e (R\u00e9publique de)<\/option><option value=\"Kosovo\"  class=\"choice-131 depth-1\"  >Kosovo<\/option><option value=\"Kowe\u00eft\"  class=\"choice-132 depth-1\"  >Kowe\u00eft<\/option><option value=\"Lesotho\"  class=\"choice-133 depth-1\"  >Lesotho<\/option><option value=\"Lettonie\"  class=\"choice-134 depth-1\"  >Lettonie<\/option><option value=\"Liban\"  class=\"choice-135 depth-1\"  >Liban<\/option><option value=\"Lib\u00e9ria\"  class=\"choice-136 depth-1\"  >Lib\u00e9ria<\/option><option value=\"Libye\"  class=\"choice-137 depth-1\"  >Libye<\/option><option value=\"Liechtenstein\"  class=\"choice-138 depth-1\"  >Liechtenstein<\/option><option value=\"Lituanie\"  class=\"choice-139 depth-1\"  >Lituanie<\/option><option value=\"Luxembourg\"  class=\"choice-140 depth-1\"  >Luxembourg<\/option><option value=\"Macao\"  class=\"choice-141 depth-1\"  >Macao<\/option><option value=\"Mac\u00e9doine du Nord (R\u00e9publique de)\"  class=\"choice-142 depth-1\"  >Mac\u00e9doine du Nord (R\u00e9publique de)<\/option><option value=\"Madagascar\"  class=\"choice-143 depth-1\"  >Madagascar<\/option><option value=\"Jersey\"  class=\"choice-144 depth-1\"  >Jersey<\/option><option value=\"Malawi\"  class=\"choice-145 depth-1\"  >Malawi<\/option><option value=\"Maldives\"  class=\"choice-146 depth-1\"  >Maldives<\/option><option value=\"Malaisie\"  class=\"choice-147 depth-1\"  >Malaisie<\/option><option value=\"Mali\"  class=\"choice-148 depth-1\"  >Mali<\/option><option value=\"Malte\"  class=\"choice-149 depth-1\"  >Malte<\/option><option value=\"Maroc\"  class=\"choice-150 depth-1\"  >Maroc<\/option><option value=\"Martinique\"  class=\"choice-151 depth-1\"  >Martinique<\/option><option value=\"Mauritanie\"  class=\"choice-152 depth-1\"  >Mauritanie<\/option><option value=\"Maurice\"  class=\"choice-153 depth-1\"  >Maurice<\/option><option value=\"Mayotte\"  class=\"choice-154 depth-1\"  >Mayotte<\/option><option value=\"Mexique\"  class=\"choice-155 depth-1\"  >Mexique<\/option><option value=\"Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)\"  class=\"choice-156 depth-1\"  >Micron\u00e9sie (Conf\u00e9d\u00e9ration des \u00c9tats de)<\/option><option value=\"Moldavie (R\u00e9publique de)\"  class=\"choice-157 depth-1\"  >Moldavie (R\u00e9publique de)<\/option><option value=\"Monaco\"  class=\"choice-158 depth-1\"  >Monaco<\/option><option value=\"Mongolie\"  class=\"choice-159 depth-1\"  >Mongolie<\/option><option value=\"Mont\u00e9n\u00e9gro\"  class=\"choice-160 depth-1\"  >Mont\u00e9n\u00e9gro<\/option><option value=\"Montserrat\"  class=\"choice-161 depth-1\"  >Montserrat<\/option><option value=\"Mozambique\"  class=\"choice-162 depth-1\"  >Mozambique<\/option><option value=\"Namibie\"  class=\"choice-163 depth-1\"  >Namibie<\/option><option value=\"Nauru\"  class=\"choice-164 depth-1\"  >Nauru<\/option><option value=\"N\u00e9pal\"  class=\"choice-165 depth-1\"  >N\u00e9pal<\/option><option value=\"Nicaragua\"  class=\"choice-166 depth-1\"  >Nicaragua<\/option><option value=\"Niger\"  class=\"choice-167 depth-1\"  >Niger<\/option><option value=\"Nig\u00e9ria\"  class=\"choice-168 depth-1\"  >Nig\u00e9ria<\/option><option value=\"Niue\"  class=\"choice-169 depth-1\"  >Niue<\/option><option value=\"Norv\u00e8ge\"  class=\"choice-170 depth-1\"  >Norv\u00e8ge<\/option><option value=\"Nouvelle-Cal\u00e9donie\"  class=\"choice-171 depth-1\"  >Nouvelle-Cal\u00e9donie<\/option><option value=\"Nouvelle-Z\u00e9lande\"  class=\"choice-172 depth-1\"  >Nouvelle-Z\u00e9lande<\/option><option value=\"Oman\"  class=\"choice-173 depth-1\"  >Oman<\/option><option value=\"Les Pays-Bas\"  class=\"choice-174 depth-1\"  >Les Pays-Bas<\/option><option value=\"Le Pakistan\"  class=\"choice-175 depth-1\"  >Le Pakistan<\/option><option value=\"Palau\"  class=\"choice-176 depth-1\"  >Palau<\/option><option value=\"Palestine (\u00c9tat de)\"  class=\"choice-177 depth-1\"  >Palestine (\u00c9tat de)<\/option><option value=\"Panama\"  class=\"choice-178 depth-1\"  >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\"  class=\"choice-179 depth-1\"  >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\"  class=\"choice-180 depth-1\"  >Paraguay<\/option><option value=\"P\u00e9rou\"  class=\"choice-181 depth-1\"  >P\u00e9rou<\/option><option value=\"Pitcairn\"  class=\"choice-182 depth-1\"  >Pitcairn<\/option><option value=\"Pologne\"  class=\"choice-183 depth-1\"  >Pologne<\/option><option value=\"Polyn\u00e9sie fran\u00e7aise\"  class=\"choice-184 depth-1\"  >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"Porto Rico\"  class=\"choice-185 depth-1\"  >Porto Rico<\/option><option value=\"Portugal\"  class=\"choice-186 depth-1\"  >Portugal<\/option><option value=\"Qatar\"  class=\"choice-187 depth-1\"  >Qatar<\/option><option value=\"Royaume-Uni de Grande-Bretagne et d&#039;Irlande du Nord\"  class=\"choice-188 depth-1\"  >Royaume-Uni de Grande-Bretagne et d'Irlande du Nord<\/option><option value=\"R\u00e9publique arabe de Syrie\"  class=\"choice-189 depth-1\"  >R\u00e9publique arabe de Syrie<\/option><option value=\"R\u00e9publique tch\u00e8que\"  class=\"choice-190 depth-1\"  >R\u00e9publique tch\u00e8que<\/option><option value=\"R\u00e9publique centrafricaine\"  class=\"choice-191 depth-1\"  >R\u00e9publique centrafricaine<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire lao\"  class=\"choice-192 depth-1\"  >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value=\"R\u00e9publique dominicaine\"  class=\"choice-193 depth-1\"  >R\u00e9publique dominicaine<\/option><option value=\"R\u00e9union (\u00cele de)\"  class=\"choice-194 depth-1\"  >R\u00e9union (\u00cele de)<\/option><option value=\"Roumanie\"  class=\"choice-195 depth-1\"  >Roumanie<\/option><option value=\"Rwanda\"  class=\"choice-196 depth-1\"  >Rwanda<\/option><option value=\"Sahara occidental\"  class=\"choice-197 depth-1\"  >Sahara occidental<\/option><option value=\"Saint-Kitts-et-Nevis\"  class=\"choice-198 depth-1\"  >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Vincent-et-les-Grenadines\"  class=\"choice-199 depth-1\"  >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Saint-Martin (partie fran\u00e7aise)\"  class=\"choice-200 depth-1\"  >Saint-Martin (partie fran\u00e7aise)<\/option><option value=\"Samoa\"  class=\"choice-201 depth-1\"  >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\"  class=\"choice-202 depth-1\"  >Samoa am\u00e9ricaines<\/option><option value=\"Saint-Marin\"  class=\"choice-203 depth-1\"  >Saint-Marin<\/option><option value=\"Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha\"  class=\"choice-204 depth-1\"  >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value=\"Sainte-Lucie\"  class=\"choice-205 depth-1\"  >Sainte-Lucie<\/option><option value=\"Sao Tom\u00e9 et Principe\"  class=\"choice-206 depth-1\"  >Sao Tom\u00e9 et Principe<\/option><option value=\"S\u00e9n\u00e9gal\"  class=\"choice-207 depth-1\"  >S\u00e9n\u00e9gal<\/option><option value=\"Serbie\"  class=\"choice-208 depth-1\"  >Serbie<\/option><option value=\"Seychelles\"  class=\"choice-209 depth-1\"  >Seychelles<\/option><option value=\"Sierra Leone\"  class=\"choice-210 depth-1\"  >Sierra Leone<\/option><option value=\"Singapour\"  class=\"choice-211 depth-1\"  >Singapour<\/option><option value=\"Sint Maarten (partie des Pays-Bas)\"  class=\"choice-212 depth-1\"  >Sint Maarten (partie des Pays-Bas)<\/option><option value=\"Slovaquie\"  class=\"choice-213 depth-1\"  >Slovaquie<\/option><option value=\"Slov\u00e9nie\"  class=\"choice-214 depth-1\"  >Slov\u00e9nie<\/option><option value=\"Somalie\"  class=\"choice-215 depth-1\"  >Somalie<\/option><option value=\"Espagne\"  class=\"choice-216 depth-1\"  >Espagne<\/option><option value=\"Sri Lanka\"  class=\"choice-217 depth-1\"  >Sri Lanka<\/option><option value=\"\u00c9tats-Unis d&#039;Am\u00e9rique\"  class=\"choice-218 depth-1\"  >\u00c9tats-Unis d'Am\u00e9rique<\/option><option value=\"\u00c9tat de la Cit\u00e9 du Vatican\"  class=\"choice-219 depth-1\"  >\u00c9tat de la Cit\u00e9 du Vatican<\/option><option value=\"Afrique du Sud\"  class=\"choice-220 depth-1\"  >Afrique du Sud<\/option><option value=\"Soudan\"  class=\"choice-221 depth-1\"  >Soudan<\/option><option value=\"Sud Soudan\"  class=\"choice-222 depth-1\"  >Sud Soudan<\/option><option value=\"Suriname\"  class=\"choice-223 depth-1\"  >Suriname<\/option><option value=\"Su\u00e8de\"  class=\"choice-224 depth-1\"  >Su\u00e8de<\/option><option value=\"Suisse\"  selected='selected' class=\"choice-225 depth-1\"  >Suisse<\/option><option value=\"Tadjikistan\"  class=\"choice-226 depth-1\"  >Tadjikistan<\/option><option value=\"Ta\u00efwan, R\u00e9publique de Chine\"  class=\"choice-227 depth-1\"  >Ta\u00efwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie (R\u00e9publique-Unie de)\"  class=\"choice-228 depth-1\"  >Tanzanie (R\u00e9publique-Unie de)<\/option><option value=\"Les Terres australes fran\u00e7aises\"  class=\"choice-229 depth-1\"  >Les Terres australes fran\u00e7aises<\/option><option value=\"Territoire britannique dans l&#039;oc\u00e9an Indien\"  class=\"choice-230 depth-1\"  >Territoire britannique dans l'oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\"  class=\"choice-231 depth-1\"  >Tha\u00eflande<\/option><option value=\"Timor oriental\"  class=\"choice-232 depth-1\"  >Timor oriental<\/option><option value=\"Togo\"  class=\"choice-233 depth-1\"  >Togo<\/option><option value=\"Tokelau\"  class=\"choice-234 depth-1\"  >Tokelau<\/option><option value=\"Tonga\"  class=\"choice-235 depth-1\"  >Tonga<\/option><option value=\"Trinit\u00e9-et-Tobago\"  class=\"choice-236 depth-1\"  >Trinit\u00e9-et-Tobago<\/option><option value=\"Tunisie\"  class=\"choice-237 depth-1\"  >Tunisie<\/option><option value=\"Turquie\"  class=\"choice-238 depth-1\"  >Turquie<\/option><option value=\"Turkm\u00e9nistan\"  class=\"choice-239 depth-1\"  >Turkm\u00e9nistan<\/option><option value=\"Tuvalu\"  class=\"choice-240 depth-1\"  >Tuvalu<\/option><option value=\"Ukraine\"  class=\"choice-241 depth-1\"  >Ukraine<\/option><option value=\"Ouganda\"  class=\"choice-242 depth-1\"  >Ouganda<\/option><option value=\"Hongrie\"  class=\"choice-243 depth-1\"  >Hongrie<\/option><option value=\"Uruguay\"  class=\"choice-244 depth-1\"  >Uruguay<\/option><option value=\"Ouzb\u00e9kistan\"  class=\"choice-245 depth-1\"  >Ouzb\u00e9kistan<\/option><option value=\"Vanuatu\"  class=\"choice-246 depth-1\"  >Vanuatu<\/option><option value=\"Venezuela (R\u00e9publique bolivarienne du)\"  class=\"choice-247 depth-1\"  >Venezuela (R\u00e9publique bolivarienne du)<\/option><option value=\"Vietnam\"  class=\"choice-248 depth-1\"  >Vietnam<\/option><option value=\"Wallis et Futuna\"  class=\"choice-249 depth-1\"  >Wallis et Futuna<\/option><option value=\"Y\u00e9men\"  class=\"choice-250 depth-1\"  >Y\u00e9men<\/option><option value=\"Zambie\"  class=\"choice-251 depth-1\"  >Zambie<\/option><option value=\"Zimbabwe\"  class=\"choice-252 depth-1\"  >Zimbabwe<\/option><option value=\"eSwatini (Royaume de)\"  class=\"choice-253 depth-1\"  >eSwatini (Royaume de)<\/option><\/select><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_60-container\" class=\"wpforms-field wpforms-field-address wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"60\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_60\">Adresse <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-58-field_60\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][60][address1]\" placeholder=\"Adresse\" required><label for=\"wpforms-58-field_60\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-58-field_60-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][60][city]\" placeholder=\"Villes\" required><label for=\"wpforms-58-field_60-city\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-58-field_60-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][60][state]\" placeholder=\"Canton\" required><label for=\"wpforms-58-field_60-state\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_61-container\" class=\"wpforms-field wpforms-field-phone wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"61\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_61\">T\u00e9l\u00e9phone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-58-field_61\" class=\"wpforms-field-large wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][61]\" placeholder=\"T\u00e9l\u00e9phone\" aria-label=\"T\u00e9l\u00e9phone\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_62-container\" class=\"wpforms-field wpforms-field-email wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_62\">Courriel<\/label><input type=\"email\" id=\"wpforms-58-field_62\" class=\"wpforms-field-large\" name=\"wpforms[fields][62]\" placeholder=\"Courriel\" spellcheck=\"false\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_63-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_63\">Personne de contact et fonction respective <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-58-field_63\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][63]\" placeholder=\"Personne de contact et fonction respective (ins\u00e9rer : nom et pr\u00e9nom, relation avec le patient)\" required><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_100-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"100\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_101-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"101\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_101\">Compagnie d&#039;assurance<\/label><input type=\"text\" id=\"wpforms-58-field_101\" class=\"wpforms-field-large\" name=\"wpforms[fields][101]\" placeholder=\"Compagnie d&#039;assurance\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_102-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"102\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_102\">AVS<\/label><input type=\"text\" id=\"wpforms-58-field_102\" class=\"wpforms-field-large\" name=\"wpforms[fields][102]\" placeholder=\"AVS\" ><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-58-field_103-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_103\">Num\u00e9ro d&#039;assur\u00e9<\/label><input type=\"text\" id=\"wpforms-58-field_103\" class=\"wpforms-field-large\" name=\"wpforms[fields][103]\" placeholder=\"Num\u00e9ro d&#039;assur\u00e9\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_67-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"67\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tMotif du contact\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_68-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_68\">Diagnostic principal <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_68\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][68]\" placeholder=\"Diagnostic principal sp\u00e9cifique\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"71\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_71\">Diagnostics secondaires sp\u00e9cifiques   <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_71\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][71]\" placeholder=\"Diagnostics secondaires fondamentaux\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_82-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"82\" style=\"display:none;\"><label class=\"wpforms-field-label\">Services requis <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_82\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_1\" name=\"wpforms[fields][82][]\" value=\"Services de soins de base\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_1\">Services de soins de base<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_2\" name=\"wpforms[fields][82][]\" value=\"Services de soins infirmiers\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_2\">Services de soins infirmiers<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_4\" name=\"wpforms[fields][82][]\" value=\"Services de soins infirmiers sp\u00e9cialis\u00e9s\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_4\">Services de soins infirmiers sp\u00e9cialis\u00e9s<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_7\" name=\"wpforms[fields][82][]\" value=\"Services priv\u00e9s\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_7\">Services priv\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_6\" name=\"wpforms[fields][82][]\" value=\"Performances internationales\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_6\">Performances internationales<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_9\" name=\"wpforms[fields][82][]\" value=\"Service de t\u00e9l\u00e9m\u00e9decine\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_9\">Service de t\u00e9l\u00e9m\u00e9decine<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-58-field_82_8\" name=\"wpforms[fields][82][]\" value=\"Service de t\u00e9l\u00e9assistance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_82_8\">Service de t\u00e9l\u00e9assistance<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_72-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"72\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_72\">Nombre d&#039;interventions n\u00e9cessaires <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-58-field_72\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][72]\" placeholder=\"Quantit\u00e9 sp\u00e9cifique d&#039;interventions\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-58-field_70-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-58-field_70\">Demande de prise en charge <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-58-field_70\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][70][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_77-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"77\" style=\"display:none;\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tDegr\u00e9 de priorit\u00e9\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_78-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"78\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\">Choix multiple <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_1\" name=\"wpforms[fields][78]\" value=\"Faible\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_1\">Faible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_2\" name=\"wpforms[fields][78]\" value=\"Moyen\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_2\">Moyen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_3\" name=\"wpforms[fields][78]\" value=\"Haut\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_3\">Haut<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-58-field_78_4\" name=\"wpforms[fields][78]\" value=\"Demande d&#039;informations d\u00e9taill\u00e9es sur le service\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_78_4\">Demande d'informations d\u00e9taill\u00e9es sur le service<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-58-field_79-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"79\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-58-field_79\">Texte suppl\u00e9mentaire<\/label><textarea id=\"wpforms-58-field_79\" class=\"wpforms-field-medium\" name=\"wpforms[fields][79]\" placeholder=\"Texte suppl\u00e9mentaire\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-58-field_8-container\" class=\"wpforms-field wpforms-field-gdpr-checkbox flagPrivacy wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"8\"><label class=\"wpforms-field-label wpforms-label-hide\">Consentement Politique de confidentialit\u00e9 <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-58-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-58-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Consentement au traitement des donn\u00e9es personnelles : je d\u00e9clare avoir lu la politique de confidentialit\u00e9 et consens au traitement de mes donn\u00e9es personnelles dans le but de fournir le service demand\u00e9.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-58-field_8_1\">Consentement au traitement des donn\u00e9es personnelles : je d\u00e9clare avoir lu la politique de confidentialit\u00e9 et consens au traitement de mes donn\u00e9es personnelles dans le but de fournir le service demand\u00e9. <span class=\"wpforms-required-label\">*<\/span><\/label><\/li><\/ul><div class=\"wpforms-field-description\">Voir la <a href=\"https:\/\/cad.healthcare\/fr\/politique-de-confidentialite\/\" target=\"_blank\">politique de confidentialit\u00e9<\/a><\/div><\/div><div id=\"wpforms-58-field_6-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"6\"><input type=\"hidden\" id=\"wpforms-58-field_6\" name=\"wpforms[fields][6]\"><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-58-field-hp\" class=\"wpforms-field-label\">Phone<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-58-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"58\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/cad.healthcare\/fr\/wp-json\/wp\/v2\/pages\/1933\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-58\" class=\"wpforms-submit\" data-alt-text=\"ENVOI EN COURS...\" data-submit-text=\"ENVOYER\" aria-live=\"assertive\" value=\"wpforms-submit\">ENVOYER<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\t\t\t\t<\/div>\n\t\t\t<\/div><\/p>\n","protected":false},"author":6,"featured_media":0,"parent":0,"menu_order":70,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","inline_featured_image":false,"footnotes":""},"class_list":["post-1933","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Contact | CAD, interventions \u00e0 domicile 24h\/24 dans le Tessin<\/title>\n<meta name=\"description\" content=\"Vous avez besoin d&#039;une assistance \u00e0 domicile rapide et personnalis\u00e9e? 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