{"id":14849,"date":"2021-03-17T09:01:38","date_gmt":"2021-03-17T08:01:38","guid":{"rendered":"https:\/\/www.rueckenwindplus.ch\/inscription\/"},"modified":"2026-08-06T16:30:01","modified_gmt":"2026-08-06T14:30:01","slug":"inscription","status":"publish","type":"page","link":"https:\/\/www.rueckenwindplus.ch\/fr\/inscription\/","title":{"rendered":"Inscription"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"14849\" class=\"elementor elementor-14849 elementor-609\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0ca5182 elementor-section-height-min-height elementor-section-full_width split-section elementor-section-content-top elementor-section-items-bottom elementor-section-height-default parallax_section_no qode_elementor_container_no qode-content-aligment-left\" data-id=\"0ca5182\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1721fb0\" data-id=\"1721fb0\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;gradient&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-621ffd1 elementor-section-boxed elementor-section-height-default elementor-section-height-default parallax_section_no qode_elementor_container_no qode-content-aligment-left\" data-id=\"621ffd1\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-0f588f7\" data-id=\"0f588f7\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-2bf8690\" data-id=\"2bf8690\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5782be7 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"5782be7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Se connecter<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-6760216\" data-id=\"6760216\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9b86ba0 elementor-widget__width-auto stoererbutton-notfall fourth elementor-invisible elementor-widget elementor-widget-button\" data-id=\"9b86ba0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeIn&quot;,&quot;_animation_delay&quot;:300}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"tel:+41562650176\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-phone\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Urgence<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-262b994 elementor-section-boxed elementor-section-height-default elementor-section-height-default parallax_section_no qode_elementor_container_no qode-content-aligment-left\" data-id=\"262b994\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-64d4a56\" data-id=\"64d4a56\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-fba9828\" data-id=\"fba9828\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4b3829b elementor-widget elementor-widget-text-editor\" data-id=\"4b3829b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<h3>Informations patient requises<\/h3>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2909d49 elementor-widget elementor-widget-text-editor\" data-id=\"2909d49\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Pour un s\u00e9jour chez \u00ab R\u00fcckenwind plus \u00bb, nous vous prions de nous fournir les informations suivantes :<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a2d4bee elementor-widget elementor-widget-text-editor\" data-id=\"a2d4bee\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<ul><li>Rapport m\u00e9dical avec diagnostics<\/li><li>Liste actuelle des m\u00e9dicaments<\/li><li>Copie de la carte d\u2019assurance maladie<\/li><li>Plan de soins (p. ex. de Spitex, si disponible)<\/li><li>Directives anticip\u00e9es (si disponibles) <\/li><\/ul>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-21d73a6 elementor-widget elementor-widget-text-editor\" data-id=\"21d73a6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>L\u2019inscription est possible par t\u00e9l\u00e9phone au <a href=\"tel:+41562650176\">+41 (0)56 265 01 76<\/a> ou via le formulaire ci-dessous.<\/p>\n<p>Veuillez toujours annoncer les admissions d\u2019urgence par t\u00e9l\u00e9phone.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-7fe89f6\" data-id=\"7fe89f6\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-9968212 elementor-section-boxed elementor-section-height-default elementor-section-height-default parallax_section_no qode_elementor_container_no qode-content-aligment-left\" data-id=\"9968212\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-aa95756\" data-id=\"aa95756\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-d0276c8\" data-id=\"d0276c8\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7b1d30c elementor-widget elementor-widget-shortcode\" 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data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><li id=\"field_2_74\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_2_74' class='gfield_label gform-field-label' for='input_2_74'><span class='gform-field-label__text'>LinkedIn<\/span><\/label><div class='ginput_container'><input name='input_74' id='input_2_74' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_74'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/li><li id=\"field_2_21\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"e3b26dd0\" data-field-span=\"12\"><h3>Informations sur le\/la patient(e)<\/h3><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"11ce0c6e\" data-field-span=\"12\"><label id='gfield_label_2_10' class='gfield_label gform-field-label' for='input_2_10'><span class='gform-field-label__text'>Nom<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"e27fb245\" data-field-span=\"12\"><label id='gfield_label_2_13' class='gfield_label gform-field-label' for='input_2_13'><span class='gform-field-label__text'>Pr\u00e9nom<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"31355c39\" data-field-span=\"12\"><label id='gfield_label_2_15' class='gfield_label gform-field-label' for='input_2_15'><span class='gform-field-label__text'>Rue<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"adeb9bc7\" data-field-span=\"12\"><label id='gfield_label_2_17' class='gfield_label gform-field-label' for='input_2_17'><span class='gform-field-label__text'>N\u00b0 postal, localit\u00e9<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"b2aadcd8\" data-field-span=\"12\"><label id='gfield_label_2_19' class='gfield_label gform-field-label' for='input_2_19'><span class='gform-field-label__text'>Date de naissance<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/jj\/aaaa'\n\t\t\t\t\tid='input_2_19'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_19'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_19' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_19' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_19' aria-label='Date de naissance: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"cfdc719a\" data-field-span=\"12\"><label id='gfield_label_2_20' class='gfield_label gform-field-label' for='input_2_20'><span class='gform-field-label__text'>E-mail<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_20' id='input_2_20' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a73ec956\" data-field-span=\"12\"><label id='gfield_label_2_11' class='gfield_label gform-field-label' for='input_2_11'><span class='gform-field-label__text'>T\u00e9l\u00e9phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_2_11' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"063dc25f\" data-field-span=\"12\"><label id='gfield_label_2_14' class='gfield_label gform-field-label' for='input_2_14'><span class='gform-field-label__text'>Langue maternelle<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a8766bfe\" data-field-span=\"12\"><label id='gfield_label_2_16' class='gfield_label gform-field-label' for='input_2_16'><span class='gform-field-label__text'>Nationalit\u00e9<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"bbec506b\" data-field-span=\"12\"><label id='gfield_label_2_18' class='gfield_label gform-field-label' for='input_2_18'><span class='gform-field-label__text'>\u00c9tat civil<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"20729201\" data-field-span=\"12\"><hr\/><\/li><li id=\"field_2_42\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2cb96ccb\" data-field-span=\"12\"><label id='gfield_label_2_42' class='gfield_label gform-field-label' for='input_2_42'><span class='gform-field-label__text'>Optionnel<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_2_42' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>veuillez choisir<\/option><option value='Personne de contact' >Personne de contact<\/option><option value='Curateur' >Curateur<\/option><\/select><\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a56333ac\" data-field-span=\"12\"><label id='gfield_label_2_25' class='gfield_label gform-field-label' for='input_2_25'><span class='gform-field-label__text'>Nom<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"89001db2\" data-field-span=\"12\"><label id='gfield_label_2_26' class='gfield_label gform-field-label' for='input_2_26'><span class='gform-field-label__text'>T\u00e9l\u00e9phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_2_26' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"bc01cd84\" data-field-span=\"12\"><hr\/><\/li><li id=\"field_2_48\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"b6215f14\" data-field-span=\"12\"><h3>Assurance maladie<\/h3><\/li><li id=\"field_2_29\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"3a1096fb\" data-field-span=\"12\"><label id='gfield_label_2_29' class='gfield_label gform-field-label' for='input_2_29'><span class='gform-field-label__text'>Assurance de base<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_34\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"92e3c32e\" data-field-span=\"12\"><label id='gfield_label_2_34' class='gfield_label gform-field-label' for='input_2_34'><span class='gform-field-label__text'>N\u00b0 d\u2019assur\u00e9<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_2_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_30\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0ba666ba\" data-field-span=\"12\"><label id='gfield_label_2_30' class='gfield_label gform-field-label' for='input_2_30'><span class='gform-field-label__text'>Assurance compl\u00e9mentaire<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_2_30' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_35\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"44fe45f1\" data-field-span=\"12\"><label id='gfield_label_2_35' class='gfield_label gform-field-label' for='input_2_35'><span class='gform-field-label__text'>N\u00b0 d\u2019assur\u00e9<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_2_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_43\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"573a60be\" data-field-span=\"12\"><label id='gfield_label_2_43' class='gfield_label gform-field-label' for='input_2_43'><span class='gform-field-label__text'>Niveau d\u2019assurance<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_2_43' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>veuillez choisir<\/option><option value='G\u00e9n\u00e9ral' >G\u00e9n\u00e9ral<\/option><option value='Semi-priv\u00e9' >Semi-priv\u00e9<\/option><option value='Priv\u00e9' >Priv\u00e9<\/option><option value='Auto-payeur \/ Upgrade' >Auto-payeur \/ Upgrade<\/option><\/select><\/div><\/li><li id=\"field_2_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"03827a83\" data-field-span=\"12\"><hr\/><\/li><li id=\"field_2_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0b595ed0\" data-field-span=\"12\"><label id='gfield_label_2_39' class='gfield_label gform-field-label' for='input_2_39'><span class='gform-field-label__text'>Diagnostics (selon CIM et par mots-cl\u00e9s)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_2_39' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d0afbfca\" data-field-span=\"12\"><label id='gfield_label_2_40' class='gfield_label gform-field-label' for='input_2_40'><span class='gform-field-label__text'>Motif d\u2019affectation \/ sympt\u00f4mes actuels \/ objectif du traitement<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_2_40' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"5820e476\" data-field-span=\"12\"><hr\/><\/li><li id=\"field_2_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"2233ddc9\" data-field-span=\"12\"><label id='gfield_label_2_46' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>M\u00e9dication actuelle<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_46'><li class='gchoice gchoice_2_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='voir annexe (note : pour m\u00e9dication importante)'  id='choice_2_46_1'    aria-labelledby=\"label_2_46_1 gfield_label_2_46\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1' class='gform-field-label gform-field-label--type-inline'>voir annexe (note : pour m\u00e9dication importante)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_45\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\" data-group-id=\"3193371a\" data-field-span=\"12\"><label id='gfield_label_2_45' class='gfield_label gform-field-label' for='input_2_45'><span class='gform-field-label__text'>M\u00e9dication actuelle (texte)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_2_45' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_54\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"cbc034a5\" data-field-span=\"12\"><hr\/><\/li><li id=\"field_2_28\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"c00947e2\" data-field-span=\"12\"><h3>Accords \/ prise de contact<\/h3><\/li><li id=\"field_2_50\" class=\"gfield gfield--type-select gfield--input-type-select gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"03bfe5f8\" data-field-span=\"12\"><label id='gfield_label_2_50' class='gfield_label gform-field-label' for='input_2_50'><span class='gform-field-label__text'>Entretien pr\u00e9alable souhait\u00e9<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_2_50' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>veuillez choisir<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_2_51\" class=\"gfield gfield--type-select gfield--input-type-select gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"376b5a39\" data-field-span=\"12\"><label id='gfield_label_2_51' class='gfield_label gform-field-label' for='input_2_51'><span class='gform-field-label__text'>Rappel souhait\u00e9<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_51' id='input_2_51' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>veuillez choisir<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_2_52\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"08eee60a\" data-field-span=\"12\"><label id='gfield_label_2_52' class='gfield_label gform-field-label' for='input_2_52'><span class='gform-field-label__text'>Rapports joints en PDF<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_2_52' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>veuillez choisir<\/option><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/li><li id=\"field_2_38\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"943a1b2d\" data-field-span=\"12\"><hr\/><\/li><li id=\"field_2_53\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ebccffba\" data-field-span=\"12\"><h3>Prescripteur<\/h3><\/li><li id=\"field_2_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6d8e0922\" data-field-span=\"12\"><label id='gfield_label_2_55' class='gfield_label gform-field-label' for='input_2_55'><span class='gform-field-label__text'>Institution<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_2_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_56\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6027cc67\" data-field-span=\"12\"><label id='gfield_label_2_56' class='gfield_label gform-field-label' for='input_2_56'><span class='gform-field-label__text'>Nom<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_2_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_57\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d17fa1f7\" data-field-span=\"12\"><label id='gfield_label_2_57' class='gfield_label gform-field-label' for='input_2_57'><span class='gform-field-label__text'>Pr\u00e9nom<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"88b91d4b\" data-field-span=\"12\"><label id='gfield_label_2_58' class='gfield_label gform-field-label' for='input_2_58'><span class='gform-field-label__text'>Fonction<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_2_58' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_59\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ac43a0ba\" data-field-span=\"12\"><label id='gfield_label_2_59' class='gfield_label gform-field-label' for='input_2_59'><span class='gform-field-label__text'>Rue \/ Case postale<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_60\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"79d9bdbc\" data-field-span=\"12\"><label id='gfield_label_2_60' class='gfield_label gform-field-label' for='input_2_60'><span class='gform-field-label__text'>N\u00b0 postal, localit\u00e9<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_2_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_70\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"1414262d\" data-field-span=\"12\"><label id='gfield_label_2_70' class='gfield_label gform-field-label' for='input_2_70'><span class='gform-field-label__text'>T\u00e9l\u00e9phone<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_70' id='input_2_70' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/li><li id=\"field_2_71\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"d8e2d94d\" data-field-span=\"12\"><label id='gfield_label_2_71' class='gfield_label gform-field-label' for='input_2_71'><span class='gform-field-label__text'>E-mail<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_71' id='input_2_71' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_72\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"3add71a8\" data-field-span=\"12\"><label id='gfield_label_2_72' class='gfield_label gform-field-label' for='input_2_72'><span class='gform-field-label__text'>N\u00b0 GLN<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_2_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_64\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"eaa50932\" data-field-span=\"12\"><hr\/><\/li><li id=\"field_2_65\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"874c1643\" data-field-span=\"12\"><h3>M\u00e9decin de famille<\/h3><\/li><li id=\"field_2_66\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"c36bb9fd\" data-field-span=\"12\"><label id='gfield_label_2_66' class='gfield_label gform-field-label' for='input_2_66'><span class='gform-field-label__text'>Nom<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_2_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_67\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a7fa1426\" data-field-span=\"12\"><label id='gfield_label_2_67' class='gfield_label gform-field-label' for='input_2_67'><span class='gform-field-label__text'>Pr\u00e9nom<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_2_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_68\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"6ced9885\" data-field-span=\"12\"><label id='gfield_label_2_68' class='gfield_label gform-field-label' for='input_2_68'><span class='gform-field-label__text'>Rue \/ Case postale<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_2_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_69\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"5b1addf3\" data-field-span=\"12\"><label id='gfield_label_2_69' class='gfield_label gform-field-label' for='input_2_69'><span class='gform-field-label__text'>N\u00b0 postal, localit\u00e9<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_2_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_61\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"bb92b79d\" data-field-span=\"12\"><label id='gfield_label_2_61' class='gfield_label gform-field-label' for='input_2_61'><span class='gform-field-label__text'>T\u00e9l\u00e9phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_61' id='input_2_61' type='tel' value='' class='large'    aria-invalid=\"false\"    \/><\/div><\/li><li id=\"field_2_62\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"55852b72\" data-field-span=\"12\"><label id='gfield_label_2_62' class='gfield_label gform-field-label' for='input_2_62'><span class='gform-field-label__text'>E-mail<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_62' id='input_2_62' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_2_63\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"31feade2\" data-field-span=\"12\"><label id='gfield_label_2_63' class='gfield_label gform-field-label' for='input_2_63'><span class='gform-field-label__text'>N\u00b0 GLN<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_2_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_73\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"5dbb90bd\" data-field-span=\"12\"><label id='gfield_label_2_73' class='gfield_label gform-field-label' for='gform_browse_button_2_73'><span class='gform-field-label__text'>Annexes<\/span><\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_2_73' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_2_73&quot;,&quot;container&quot;:&quot;gform_multifile_upload_2_73&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_2_73&quot;,&quot;filelist&quot;:&quot;gform_preview_2_73&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.rueckenwindplus.ch\\\/fr\\\/?gf_page=30bb6b17ea9947b&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.rueckenwindplus.ch\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.rueckenwindplus.ch\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;png,pdf,jpg,jpeg,gif&quot;}],&quot;max_file_size&quot;:&quot;268435456b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:2,&quot;field_id&quot;:73,&quot;_gform_file_upload_nonce_2_73&quot;:&quot;1f9a814ab7&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_2_73&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_2_73' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_2_73' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_2_73\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_73'>Types de fichiers accept\u00e9s\u00a0: png, pdf, jpg, jpeg, gif, Taille max. des fichiers\u00a0: 256 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_2_73'><\/ul> <div id='gform_preview_2_73' class='ginput_preview_list'><\/div><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Envoyer<\/button> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=bdcc45f7158de1c0daced8893d3f93c8' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CHF' value='f3tUP2kLuB8A4lvuGmZGYhM7k7Z3myhXunOtLw\/SkNFsg\/zPIzkPFLJhzdr24seMUWLOM1aOmF6YxTj0g1K\/KqY4CKb7HsF5A3WcZOZnxiDDNjw=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_2' value='' \/>\n        <\/div>\n                        <input type=\"hidden\" id=\"ct_checkjs_ab233b682ec355648e7891e66c54191b\" name=\"ct_checkjs\" value=\"0\" \/><script>setTimeout(function(){var ct_input_name = \"ct_checkjs_ab233b682ec355648e7891e66c54191b\";if (document.getElementById(ct_input_name) !== null) {var ct_input_value = document.getElementById(ct_input_name).value;document.getElementById(ct_input_name).value = document.getElementById(ct_input_name).value.replace(ct_input_value, '1213543721');}}, 1000);<\/script><input\n                    class=\"apbct_special_field apbct_email_id__gravity_form\"\n                    name=\"apbct__email_id__gravity_form\"\n                    aria-label=\"apbct__label_id__gravity_form\"\n                    type=\"text\" size=\"30\" maxlength=\"200\" autocomplete=\"off\"\n                    value=\"\"\n                \/><\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_2' id='gform_ajax_frame_2' title='Cette iframe contient la logique n\u00e9cessaire pour manipuler Gravity Forms avec Ajax.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_2').offset().top - mt); }, 50 );var current_page = jQuery('#gform_source_page_number_2').val();jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content 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