{"id":3093,"date":"2022-08-17T14:00:09","date_gmt":"2022-08-17T12:00:09","guid":{"rendered":"https:\/\/cptsdracenie.fr\/?page_id=3093"},"modified":"2026-04-10T17:51:05","modified_gmt":"2026-04-10T15:51:05","slug":"formulaire-de-demande-de-medecin-traitant","status":"publish","type":"page","link":"https:\/\/cptsdracenie.fr\/index.php\/mission-de-sante\/acces-aux-medecins\/formulaire-de-demande-de-medecin-traitant\/","title":{"rendered":"Formulaire de demande de m\u00e9decin traitant"},"content":{"rendered":"<div data-colibri-id=\"3093-c1\" class=\"style-3442 style-local-3093-c1 position-relative\">\n  <!---->\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c61\" id=\"about\" class=\"h-section h-section-global-spacing d-flex align-items-lg-center align-items-md-center align-items-center style-5456 style-local-3093-c61 position-relative\">\n    <!---->\n    <!---->\n    <div class=\"h-section-grid-container h-section-boxed-container\">\n      <!---->\n      <div data-colibri-id=\"3093-c62\" class=\"h-row-container gutters-row-lg-0 gutters-row-md-0 gutters-row-0 gutters-row-v-lg-0 gutters-row-v-md-0 gutters-row-v-0 style-5457 style-local-3093-c62 position-relative\">\n        <!---->\n        <div class=\"h-row justify-content-lg-center justify-content-md-center justify-content-center align-items-lg-stretch align-items-md-stretch align-items-stretch gutters-col-lg-0 gutters-col-md-0 gutters-col-0 gutters-col-v-lg-0 gutters-col-v-md-0 gutters-col-v-0\">\n          <!---->\n          <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-5458-outer style-local-3093-c63-outer\">\n            <div data-colibri-id=\"3093-c63\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-0 h-px-md-0 h-px-0 v-inner-lg-0 v-inner-md-0 v-inner-0 style-5458 style-local-3093-c63 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-start align-self-md-start align-self-start\">\n                <!---->\n                <div data-colibri-id=\"3093-c65\" class=\"h-global-transition-all h-heading style-5460 style-local-3093-c65 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-heading__outer style-5460 style-local-3093-c65\">\n                    <!---->\n                    <!---->\n                    <h2 class=\"\">Vous recherchez un m\u00e9decin traitant?<\/h2>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c66\" class=\"h-text h-text-component style-5461 style-local-3093-c66 position-relative h-element\">\n                  <!---->\n                  <!---->\n                  <div class=\"\">\n                    <p>Avez vous pensez \u00e0 demander \u00e0 votre sp\u00e9cialiste de vous d\u00e9clarer ? Pour les oins ponctuels des m\u00e9decins g\u00e9n\u00e9ralistes assurent des consultations ponctuelles et le suivi de votre pathologie est r\u00e9alis\u00e9 par votre sp\u00e9cialiste.<\/p>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c68\" class=\"h-x-container style-5463 style-local-3093-c68 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-x-container-inner style-dynamic-3093-c68-group style-5463-spacing style-local-3093-c68-spacing\"><span class=\"h-button__outer style-5464-outer style-local-3093-c69-outer d-inline-flex h-element\"><a h-use-smooth-scroll=\"true\" href=\"https:\/\/cptsdracenie.fr\/index.php\/mission-de-sante\/acces-aux-medecins\/certificats-medicaux-par-qui-quand-et-comment\/\"  data-colibri-id=\"3093-c69\" class=\"d-flex w-100 align-items-center h-button justify-content-lg-center justify-content-md-center justify-content-center style-5464 style-local-3093-c69 position-relative\"><!----><!----> <span>Besoin d&rsquo;un certificat ou dossier et vous n&rsquo;avez pas de m\u00e9decin traitant?<\/span><\/a>\n                    <\/span>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n          <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-5462-outer style-local-3093-c67-outer\">\n            <div data-colibri-id=\"3093-c67\" class=\"d-flex h-flex-basis h-column__inner h-ui-empty-state-container h-px-lg-2 h-px-md-2 h-px-2 v-inner-lg-2 v-inner-md-2 v-inner-2 style-5462 style-local-3093-c67 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100\">\n                <!---->\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c2\" id=\"overlappable\" class=\"h-section h-section-global-spacing d-flex align-items-lg-center align-items-md-center align-items-center style-4549 style-local-3093-c2 position-relative\">\n    <!---->\n    <!---->\n    <div class=\"h-section-grid-container h-section-boxed-container\">\n      <!---->\n      <div data-colibri-id=\"3093-c3\" class=\"h-row-container gutters-row-lg-0 gutters-row-md-0 gutters-row-2 gutters-row-v-lg-0 gutters-row-v-md-0 gutters-row-v-2 style-4550 style-local-3093-c3 position-relative\">\n        <!---->\n        <div class=\"h-row justify-content-lg-center justify-content-md-center justify-content-center align-items-lg-stretch align-items-md-stretch align-items-stretch gutters-col-lg-0 gutters-col-md-0 gutters-col-2 gutters-col-v-lg-0 gutters-col-v-md-0 gutters-col-v-2\">\n          <!---->\n          <div class=\"h-column h-column-container d-flex h-col-lg-3 h-col-md-3 h-col-12 style-4551-outer style-local-3093-c4-outer\">\n            <div data-colibri-id=\"3093-c4\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-3 h-px-md-3 h-px-2 v-inner-lg-3 v-inner-md-3 v-inner-2 style-4551 style-local-3093-c4 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                <!---->\n                <div data-colibri-id=\"3093-c5\" class=\"h-icon style-4552 style-local-3093-c5 position-relative h-element\">\n                  <!----><span class=\"h-svg-icon h-icon__icon style-4552-icon style-local-3093-c5-icon\"><!--Icon by Font Awesome (https:\/\/fontawesome.com)-->\n    <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" id=\"paper-plane\" viewBox=\"0 0 1792.0013 1896.0833\">\n      <path d=\"M1764 11q33 24 27 64l-256 1536q-5 29-32 45-14 8-31 8-11 0-24-5l-453-185-242 295q-18 23-49 23-13 0-22-4-19-7-30.5-23.5T640 1728v-349l864-1059-1069 925-395-162q-37-14-40-55-2-40 32-59L1696 9q15-9 32-9 20 0 36 11z\"><\/path>\n    <\/svg><\/span><\/div>\n                <div data-colibri-id=\"3093-c6\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c6 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c6\">\n                    <!---->\n                    <!---->\n                    <h5 class=\"\">Selon votre localisation<\/h5>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c7\" class=\"h-text h-text-component style-4554 style-local-3093-c7 position-relative h-element\">\n                  <!---->\n                  <!---->\n                  <div class=\"\">\n                    <p>Nous ne traitons que les demandes de notre territoire<\/p>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n          <div class=\"h-column h-column-container d-flex h-col-lg-3 h-col-md-3 h-col-12 style-4551-outer style-local-3093-c8-outer\">\n            <div data-colibri-id=\"3093-c8\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-3 h-px-md-3 h-px-2 v-inner-lg-3 v-inner-md-3 v-inner-2 style-4551 style-local-3093-c8 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                <!---->\n                <div data-colibri-id=\"3093-c9\" class=\"h-icon style-4552 style-local-3093-c9 position-relative h-element\">\n                  <!----><span class=\"h-svg-icon h-icon__icon style-4552-icon style-local-3093-c9-icon\"><!--Icon by Font Awesome (https:\/\/fontawesome.com)-->\n    <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" id=\"signal\" viewBox=\"0 0 1792 1896.0833\">\n      <path d=\"M256 1440v192q0 14-9 23t-23 9H32q-14 0-23-9t-9-23v-192q0-14 9-23t23-9h192q14 0 23 9t9 23zm384-128v320q0 14-9 23t-23 9H416q-14 0-23-9t-9-23v-320q0-14 9-23t23-9h192q14 0 23 9t9 23zm384-256v576q0 14-9 23t-23 9H800q-14 0-23-9t-9-23v-576q0-14 9-23t23-9h192q14 0 23 9t9 23zm384-384v960q0 14-9 23t-23 9h-192q-14 0-23-9t-9-23V672q0-14 9-23t23-9h192q14 0 23 9t9 23zm384-512v1472q0 14-9 23t-23 9h-192q-14 0-23-9t-9-23V160q0-14 9-23t23-9h192q14 0 23 9t9 23z\"><\/path>\n    <\/svg><\/span><\/div>\n                <div data-colibri-id=\"3093-c10\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c10 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c10\">\n                    <!---->\n                    <!---->\n                    <h5 class=\"\">Nous avons orient\u00e9 plus&nbsp; +de 1500 patients<\/h5>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c11\" class=\"h-text h-text-component style-4554 style-local-3093-c11 position-relative h-element\">\n                  <!---->\n                  <!---->\n                  <div class=\"\">\n                    <p>Une solution pour tous pour une prise en charge pertinente<\/p>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n          <div class=\"h-column h-column-container d-flex h-col-lg-3 h-col-md-3 h-col-12 style-4551-outer style-local-3093-c12-outer\">\n            <div data-colibri-id=\"3093-c12\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-3 h-px-md-3 h-px-2 v-inner-lg-3 v-inner-md-3 v-inner-2 style-4551 style-local-3093-c12 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                <!---->\n                <div data-colibri-id=\"3093-c13\" class=\"h-icon style-4552 style-local-3093-c13 position-relative h-element\">\n                  <!---->\n                  <a href=\"https:\/\/centrepreventiondracenie.fr\/\" h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-4552-icon style-local-3093-c13-icon\"><!--Icon by Font Awesome (https:\/\/fontawesome.com)-->\n    <svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" id=\"info\" viewBox=\"0 0 1011.9142 1896.0833\">\n      <path d=\"M640 1344v128q0 26-19 45t-45 19H64q-26 0-45-19t-19-45v-128q0-26 19-45t45-19h64V896H64q-26 0-45-19T0 832V704q0-26 19-45t45-19h384q26 0 45 19t19 45v576h64q26 0 45 19t19 45zM512 192v192q0 26-19 45t-45 19H192q-26 0-45-19t-19-45V192q0-26 19-45t45-19h256q26 0 45 19t19 45z\"><\/path>\n    <\/svg><\/span><\/a>\n                <\/div>\n                <div data-colibri-id=\"3093-c14\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c14 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c14\">\n                    <!---->\n                    <!---->\n                    <a href=\"https:\/\/centrepreventiondracenie.fr\/\" h-use-smooth-scroll=\"true\">\n                      <h5 class=\"\">des conseils<\/h5>\n                    <\/a>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c15\" class=\"h-text h-text-component style-4554 style-local-3093-c15 position-relative h-element\">\n                  <!---->\n                  <!---->\n                  <div class=\"\">\n                    <p>T\u00e9l\u00e9phonez ou rendez vous directement au centre de pr\u00e9vention en sant\u00e9&nbsp;<\/p>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n          <div class=\"h-column h-column-container d-flex h-col-lg-3 h-col-md-3 h-col-12 style-4555-outer style-local-3093-c16-outer\">\n            <div data-colibri-id=\"3093-c16\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-3 h-px-md-3 h-px-2 v-inner-lg-3 v-inner-md-3 v-inner-2 style-4555 style-local-3093-c16 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                <!---->\n                <div data-colibri-id=\"3093-c17\" class=\"h-icon style-4552 style-local-3093-c17 position-relative h-element\">\n                  <!---->\n                  <a href=\"https:\/\/www.doctolib.fr\/etablissement-de-prevention\/draguignan\/centre-de-prevention-en-sante-de-la-dracenie\/booking\/motives?specialityId=3761&amp;telehealth=false&amp;placeId=practice-575620&amp;motiveCategoryIds%5B%5D=334028&amp;profile_skipped=true&amp;bookingFunnelSource=external_referral\"\n                    h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-4552-icon style-local-3093-c17-icon\"><!--Icon by Icons8 Line Awesome (https:\/\/icons8.com\/line-awesome)--><svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" id=\"area-chart\" viewBox=\"0 0 512 545.5\"><path d=\"M448 97v383H64V204.5l19 4 73 14.5 91-60.5 5.5-3.5 6 1 89.5 15 74-58zm-32 65.5l-54 42-5.5 4.5-7-1-90-15-90.5 60.5-5.5 3.5-6.5-1.5-61-12V309l62 25 89-59.5 6.5-4 7.5 2.5 87.5 29 67.5-53.5v-86zm0 127l-54 43-7 5.5-8-3-88-29.5-90 60-7 4.5-8-3-58-23v104h320V289.5z\"><\/path><\/svg><\/span><\/a>\n                <\/div>\n                <div data-colibri-id=\"3093-c18\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c18 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c18\">\n                    <!---->\n                    <!---->\n                    <a href=\"https:\/\/www.doctolib.fr\/etablissement-de-prevention\/draguignan\/centre-de-prevention-en-sante-de-la-dracenie\/booking\/motives?specialityId=3761&amp;telehealth=false&amp;placeId=practice-575620&amp;motiveCategoryIds%5B%5D=334028&amp;profile_skipped=true&amp;bookingFunnelSource=external_referral\"\n                      h-use-smooth-scroll=\"true\">\n                      <h5 class=\"\">Le num\u00e9rique en sant\u00e9<\/h5>\n                    <\/a>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c19\" class=\"h-text h-text-component style-4554 style-local-3093-c19 position-relative h-element\">\n                  <!---->\n                  <!---->\n                  <div class=\"\">\n                    <p><span style=\"font-weight: 400; font-size: 16px; font-family: &quot;Open Sans&quot;; color: rgb(70, 112, 127);\">Nous sommes l\u00e0 pour vous accompagner par notre ambassadeur du num\u00e9rique situ\u00e9 \u00e0 Draguignan<\/span><\/p>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/div>\n      <div data-colibri-id=\"3093-c20\" class=\"h-row-container gutters-row-lg-2 gutters-row-md-2 gutters-row-0 gutters-row-v-lg-2 gutters-row-v-md-2 gutters-row-v-2 style-4556 style-local-3093-c20 position-relative\">\n        <!---->\n        <div class=\"h-row justify-content-lg-center justify-content-md-center justify-content-center align-items-lg-stretch align-items-md-stretch align-items-stretch gutters-col-lg-2 gutters-col-md-2 gutters-col-0 gutters-col-v-lg-2 gutters-col-v-md-2 gutters-col-v-2\">\n          <!---->\n          <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-4557-outer style-local-3093-c21-outer\">\n            <div data-colibri-id=\"3093-c21\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-2 h-px-md-2 h-px-2 v-inner-lg-2 v-inner-md-2 v-inner-2 style-4557 style-local-3093-c21 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-start align-self-md-start align-self-start\">\n                <!---->\n                <div data-colibri-id=\"3093-c22\" class=\"h-text h-text-component style-4548 style-local-3093-c22 position-relative h-element\">\n                  <!---->\n                  <!---->\n                  <div class=\"\">\n                    <h2>Remplissez le formulaire<\/h2>\n                    <p><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">Dans le cadre de la loi RGPD merci de valider votre demande via le mail de confirmation que vous allez recevoir apr\u00e8s avoir valid\u00e9 le formulaire.<\/span>\n                      <span\n                        style=\"font-size: 20px; color: rgb(234, 45, 22); font-weight: 400; font-family: Oswald;\">\n                        <br>Pensez \u00e0 regarder vos spams!<\/span>\n                        <br><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">1 ADRESSE MAIL PAR DEMANDE<\/span>\n                        <br><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">EN CAS DE BESOIN APPELER LE 04.98.10.05.42&nbsp;<\/span>\n                        <br><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">ou sur place au centre de pr\u00e9vention&nbsp;<\/span>\n                        <br><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">19 boulevard g\u00e9n\u00e9ral Leclerc<\/span>\n                        <br><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">83300 Draguignan<\/span><\/p>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c23\" id=\"initial-content\" class=\"h-section h-section-global-spacing d-flex align-items-lg-center align-items-md-center align-items-center style-3443 style-local-3093-c23 position-relative\">\n    <!---->\n    <!---->\n    <div class=\"h-section-grid-container h-section-boxed-container\">\n      <!---->\n      <div data-colibri-id=\"3093-c24\" class=\"h-row-container gutters-row-lg-2 gutters-row-md-2 gutters-row-0 gutters-row-v-lg-2 gutters-row-v-md-2 gutters-row-v-2 style-3454 style-local-3093-c24 position-relative\">\n        <!---->\n        <div class=\"h-row justify-content-lg-center justify-content-md-center justify-content-center align-items-lg-stretch align-items-md-stretch align-items-stretch gutters-col-lg-2 gutters-col-md-2 gutters-col-0 gutters-col-v-lg-2 gutters-col-v-md-2 gutters-col-v-2\">\n          <!---->\n          <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-3455-outer style-local-3093-c25-outer\">\n            <div data-colibri-id=\"3093-c25\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-2 h-px-md-2 h-px-2 v-inner-lg-2 v-inner-md-2 v-inner-2 style-3455 style-local-3093-c25 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-start align-self-md-start align-self-start\">\n                <!---->\n                <div data-colibri-id=\"3093-c26\" class=\"style-3803 style-local-3093-c26 position-relative h-element\">\n                  <!---->\n                  <div class=\"\">\n                    <!-- Begin Brevo Form -->\n                    <!-- START - We recommend to place the below code in head tag of your website html  -->\n                    <style>\n                      @font-face {\n                        font-display: block;\n                        font-family: Roboto;\n                        src: url(https:\/\/assets.brevo.com\/font\/Roboto\/Latin\/normal\/normal\/7529907e9eaf8ebb5220c5f9850e3811.woff2) format(\"woff2\"), url(https:\/\/assets.brevo.com\/font\/Roboto\/Latin\/normal\/normal\/25c678feafdc175a70922a116c9be3e7.woff) format(\"woff\")\n                      }\n\n                      @font-face {\n                        font-display: fallback;\n                        font-family: Roboto;\n                        font-weight: 600;\n                        src: url(https:\/\/assets.brevo.com\/font\/Roboto\/Latin\/medium\/normal\/6e9caeeafb1f3491be3e32744bc30440.woff2) format(\"woff2\"), url(https:\/\/assets.brevo.com\/font\/Roboto\/Latin\/medium\/normal\/71501f0d8d5aa95960f6475d5487d4c2.woff) format(\"woff\")\n                      }\n\n                      @font-face {\n                        font-display: fallback;\n                        font-family: Roboto;\n                        font-weight: 700;\n                        src: url(https:\/\/assets.brevo.com\/font\/Roboto\/Latin\/bold\/normal\/3ef7cf158f310cf752d5ad08cd0e7e60.woff2) format(\"woff2\"), url(https:\/\/assets.brevo.com\/font\/Roboto\/Latin\/bold\/normal\/ece3a1d82f18b60bcce0211725c476aa.woff) format(\"woff\")\n                      }\n\n                      #sib-container input:-ms-input-placeholder {\n                        text-align: left;\n                        font-family: Helvetica, sans-serif;\n                        color: #c0ccda;\n                      }\n\n                      #sib-container input::placeholder {\n                        text-align: left;\n                        font-family: Helvetica, sans-serif;\n                        color: #c0ccda;\n                      }\n\n                      #sib-container textarea::placeholder {\n                        text-align: left;\n                        font-family: Helvetica, sans-serif;\n                        color: #c0ccda;\n                      }\n\n                      #sib-container a {\n                        text-decoration: underline;\n                        color: #2BB2FC;\n                      }\n                    <\/style>\n                    <link rel=\"stylesheet\" href=\"https:\/\/sibforms.com\/forms\/end-form\/build\/sib-styles.css\">\n                    <!--  END - We recommend to place the above code in head tag of your website html -->\n\n                    <!-- START - We recommend to place the below code where you want the form in your website html  -->\n                    <div class=\"sib-form\" style=\"text-align: center;\n         background-color: #EFF2F7;                                 \">\n                      <div id=\"sib-form-container\" class=\"sib-form-container\">\n                        <div id=\"error-message\" class=\"sib-form-message-panel\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;max-width:540px;\">\n                          <div class=\"sib-form-message-panel__text sib-form-message-panel__text--center\">\n                            <svg viewBox=\"0 0 512 512\" class=\"sib-icon sib-notification__icon\">\n                              <path d=\"M256 40c118.621 0 216 96.075 216 216 0 119.291-96.61 216-216 216-119.244 0-216-96.562-216-216 0-119.203 96.602-216 216-216m0-32C119.043 8 8 119.083 8 256c0 136.997 111.043 248 248 248s248-111.003 248-248C504 119.083 392.957 8 256 8zm-11.49 120h22.979c6.823 0 12.274 5.682 11.99 12.5l-7 168c-.268 6.428-5.556 11.5-11.99 11.5h-8.979c-6.433 0-11.722-5.073-11.99-11.5l-7-168c-.283-6.818 5.167-12.5 11.99-12.5zM256 340c-15.464 0-28 12.536-28 28s12.536 28 28 28 28-12.536 28-28-12.536-28-28-28z\"><\/path>\n                            <\/svg>\n                            <span class=\"sib-form-message-panel__inner-text\">\n                          Nous n&rsquo;avons pas pu confirmer votre demande de m\u00e9decin traitant.\n                      <\/span>\n                          <\/div>\n                        <\/div>\n                        <div><\/div>\n                        <div id=\"success-message\" class=\"sib-form-message-panel\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#085229; background-color:#e7faf0; border-radius:3px; border-color:#13ce66;max-width:540px;\">\n                          <div class=\"sib-form-message-panel__text sib-form-message-panel__text--center\">\n                            <svg viewBox=\"0 0 512 512\" class=\"sib-icon sib-notification__icon\">\n                              <path d=\"M256 8C119.033 8 8 119.033 8 256s111.033 248 248 248 248-111.033 248-248S392.967 8 256 8zm0 464c-118.664 0-216-96.055-216-216 0-118.663 96.055-216 216-216 118.664 0 216 96.055 216 216 0 118.663-96.055 216-216 216zm141.63-274.961L217.15 376.071c-4.705 4.667-12.303 4.637-16.97-.068l-85.878-86.572c-4.667-4.705-4.637-12.303.068-16.97l8.52-8.451c4.705-4.667 12.303-4.637 16.97.068l68.976 69.533 163.441-162.13c4.705-4.667 12.303-4.637 16.97.068l8.451 8.52c4.668 4.705 4.637 12.303-.068 16.97z\"><\/path>\n                            <\/svg>\n                            <span class=\"sib-form-message-panel__inner-text\">\n                          Votre demande est enregistr\u00e9e merci de valider le mail pour finaliser la r\u00e9ception. Afin de fluidifier et d&rsquo;orienter votre demande, nous vous conseillons de r\u00e9aliser votre bilan de pr\u00e9vention au Centre de Pr\u00e9vention de Draguignan. Pour prendre rdv :  https:\/\/www.doctolib.fr\/etablissement-de-prevention\/draguignan\/centre-de-prevention-en-sante-de-la-dracenie\n                      <\/span>\n                          <\/div>\n                        <\/div>\n                        <div><\/div>\n                        <div id=\"sib-container\" class=\"sib-container--large sib-container--vertical\" style=\"text-align:center; background-color:rgba(255,255,255,1); max-width:540px; border-radius:3px; border-width:1px; border-color:#C0CCD9; border-style:solid; direction:ltr\">\n                          <form id=\"sib-form\" method=\"POST\" action=\"https:\/\/d17c6d89.sibforms.com\/serve\/MUIFAB60tA6AskiFaRPCR8YX79nug2_eb2WdcgChdIcmGn4jR5rQFAXR66NQX9KWffFggUC20E4ox8hg7XS3DD8SZG7G9uUZ0nseYGIRU1DAFcOe0og4jQiFrRjhGRlLHY7fPVeOsmoG-t-fQAL-elP2KwZ7Yg-Gmi0GLooOoAJtemx4t-g5SGyN28Kty06yOJzO4cz19sEoUI_3\"\n                            data-type=\"subscription\">\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-form-block\" style=\"font-size:32px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3C4858; background-color:transparent; text-align:left\">\n                                <p>Demande de m\u00e9decin traitant<\/p>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-form-block\" style=\"font-size:16px; text-align:center; font-family:Helvetica, sans-serif; color:#3f3133; background-color:transparent; text-align:center\">\n                                <div class=\"sib-text-form-block\">\n                                  <p>Votre demande sera trait\u00e9e lors de notre prochaine commission en d\u00e9but de chaque mois.<\/p>\n                                  <p>Le pharmacien est habilit\u00e9 \u00e0 renouveler 3 fois votre ordonnance habituelle de traitement.&nbsp;<\/p>\n                                  <p>Pour orienter votre demande au mieux, veuillez r\u00e9aliser votre\n                                    <a target=\"_blank\" href=\"https:\/\/www.doctolib.fr\/etablissement-de-prevention\/draguignan\/centre-de-prevention-en-sante-de-la-dracenie\">bilan de pr\u00e9vention en amont de la commission.&nbsp;<\/a>\n                                  <\/p>\n                                  <p>\n                                    <br>\n                                  <\/p>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-form-block\" style=\"font-size:16px; text-align:center; font-family:Helvetica, sans-serif; color:#e00c58; background-color:transparent; text-align:center\">\n                                <div class=\"sib-text-form-block\">\n                                  <p><strong>En cas d&rsquo;urgence merci de contacter le 15.<\/strong><\/p>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-form-block\" style=\"font-size:16px; text-align:left; font-style:italic; font-family:Helvetica, sans-serif; color:#3C4858; background-color:transparent; text-align:left\">\n                                <div class=\"sib-text-form-block\">\n                                  <p>Cartographie du territoire de la CPTS Drac\u00e9nie Provence Verdon<\/p>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-input sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"EMAIL\" data-required=\"*\">Veuillez renseigner votre adresse email pour vous inscrire<\/label>\n\n                                    <div class=\"entry__field\">\n                                      <input class=\"input \" type=\"text\" id=\"EMAIL\" name=\"EMAIL\" autocomplete=\"off\" placeholder=\"EMAIL\" data-required=\"true\" required=\"\">\n                                    <\/div>\n                                  <\/div>\n\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Veuillez renseigner votre adresse email pour vous inscrire. Ex. : abc@xyz.com\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-input sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"NOM\" data-required=\"*\">Entrez votre NOM<\/label>\n\n                                    <div class=\"entry__field\">\n                                      <input class=\"input \" maxlength=\"200\" type=\"text\" id=\"NOM\" name=\"NOM\" autocomplete=\"off\" placeholder=\"NOM\" data-required=\"true\" required=\"\">\n                                    <\/div>\n                                  <\/div>\n\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-input sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"PRENOM\" data-required=\"*\">Entrez votre PRENOM<\/label>\n\n                                    <div class=\"entry__field\">\n                                      <input class=\"input \" maxlength=\"200\" type=\"text\" id=\"PRENOM\" name=\"PRENOM\" autocomplete=\"off\" placeholder=\"PRENOM\" data-required=\"true\" required=\"\">\n                                    <\/div>\n                                  <\/div>\n\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-sms-field sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"SMS\">Entrez votre SMS<\/label>\n\n                                    <div class=\"sib-sms-input-wrapper\" style=\"direction:ltr\">\n                                      <div class=\"sib-sms-input\" data-placeholder=\"SMS\" data-required=\"\" data-country-code=\"FR\" data-whatsapp-country-code=\"FR\" data-value=\"\" data-whatsappvalue=\"\" data-attributename=\"SMS\">\n                                        <div class=\"entry__field\">\n                                          <select class=\"input\" name=\"SMS__COUNTRY_CODE\">\n                                            <option value=\"+93\">\n                                              +93 AF\n                                            <\/option>\n                                            <option value=\"+358\">\n                                              +358 AX\n                                            <\/option>\n                                            <option value=\"+355\">\n                                              +355 AL\n                                            <\/option>\n                                            <option value=\"+213\">\n                                              +213 DZ\n                                            <\/option>\n                                            <option value=\"+1684\">\n                                              +1684 AS\n                                            <\/option>\n                                            <option value=\"+376\">\n                                              +376 AD\n                                            <\/option>\n                                            <option value=\"+244\">\n                                              +244 AO\n                                            <\/option>\n                                            <option value=\"+1264\">\n                                              +1264 AI\n                                            <\/option>\n                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value=\"+47\">\n                                              +47 BV\n                                            <\/option>\n                                            <option value=\"+55\">\n                                              +55 BR\n                                            <\/option>\n                                            <option value=\"+246\">\n                                              +246 IO\n                                            <\/option>\n                                            <option value=\"+673\">\n                                              +673 BN\n                                            <\/option>\n                                            <option value=\"+359\">\n                                              +359 BG\n                                            <\/option>\n                                            <option value=\"+226\">\n                                              +226 BF\n                                 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                                         +254 KE\n                                            <\/option>\n                                            <option value=\"+686\">\n                                              +686 KI\n                                            <\/option>\n                                            <option value=\"+850\">\n                                              +850 KP\n                                            <\/option>\n                                            <option value=\"+82\">\n                                              +82 KR\n                                            <\/option>\n                                            <option value=\"+965\">\n                                              +965 KW\n                                            <\/option>\n                                            <option value=\"+996\">\n                                              +996 KG\n                                            <\/option>\n                                            <option value=\"+856\">\n                                              +856 LA\n                                            <\/option>\n                                            <option value=\"+371\">\n                                              +371 LV\n                                            <\/option>\n                                            <option value=\"+961\">\n                                              +961 LB\n                                            <\/option>\n                                            <option value=\"+266\">\n                                              +266 LS\n                                            <\/option>\n                                            <option value=\"+231\">\n                                              +231 LR\n                                            <\/option>\n                                            <option value=\"+218\">\n                                              +218 LY\n                                            <\/option>\n                                            <option value=\"+423\">\n                                              +423 LI\n                                            <\/option>\n                                            <option value=\"+370\">\n                                              +370 LT\n                                            <\/option>\n                                            <option value=\"+352\">\n                                              +352 LU\n                                            <\/option>\n                                            <option value=\"+853\">\n                                              +853 MO\n                                            <\/option>\n                                            <option value=\"+389\">\n                                              +389 MK\n                                            <\/option>\n                                            <option value=\"+261\">\n                                              +261 MG\n                                            <\/option>\n                                            <option value=\"+265\">\n                                              +265 MW\n                                            <\/option>\n                                            <option value=\"+60\">\n                                              +60 MY\n                                            <\/option>\n                                            <option value=\"+960\">\n                                              +960 MV\n                                            <\/option>\n                                            <option value=\"+223\">\n                                              +223 ML\n                                            <\/option>\n                                            <option value=\"+356\">\n                                              +356 MT\n                                            <\/option>\n                                            <option value=\"+692\">\n                                              +692 MH\n                                            <\/option>\n                                            <option value=\"+596\">\n                                              +596 MQ\n                                            <\/option>\n                                            <option value=\"+222\">\n                                              +222 MR\n                                            <\/option>\n                                            <option value=\"+230\">\n                                              +230 MU\n                                            <\/option>\n                                            <option value=\"+262\">\n                                              +262 YT\n                                            <\/option>\n                                            <option value=\"+52\">\n                                              +52 MX\n                                            <\/option>\n                                            <option value=\"+691\">\n                                              +691 FM\n                                            <\/option>\n                                            <option value=\"+373\">\n                                              +373 MD\n                                            <\/option>\n                                            <option value=\"+377\">\n                                              +377 MC\n                                            <\/option>\n                                            <option value=\"+976\">\n                                              +976 MN\n                                            <\/option>\n                                            <option value=\"+382\">\n                                              +382 ME\n                                            <\/option>\n                                            <option value=\"+1664\">\n                                              +1664 MS\n                                            <\/option>\n                                            <option value=\"+212\">\n                                              +212 MA\n                                            <\/option>\n                                            <option value=\"+258\">\n                                              +258 MZ\n                                            <\/option>\n                                            <option value=\"+95\">\n                                              +95 MM\n                                            <\/option>\n                                            <option value=\"+264\">\n                                              +264 NA\n                                            <\/option>\n                                            <option value=\"+674\">\n                                              +674 NR\n                                            <\/option>\n                                            <option value=\"+977\">\n                                              +977 NP\n                                            <\/option>\n                                            <option value=\"+31\">\n                                              +31 NL\n                                            <\/option>\n                                            <option value=\"+687\">\n                                              +687 NC\n                                            <\/option>\n                                            <option value=\"+64\">\n                                              +64 NZ\n                                            <\/option>\n                                            <option value=\"+505\">\n                                              +505 NI\n                                            <\/option>\n                                            <option value=\"+227\">\n                                              +227 NE\n                                            <\/option>\n                                            <option value=\"+234\">\n                                              +234 NG\n                                            <\/option>\n                                            <option value=\"+683\">\n                                              +683 NU\n                                            <\/option>\n                                            <option value=\"+672\">\n                                              +672 NF\n                                            <\/option>\n                                            <option value=\"+1670\">\n                                              +1670 MP\n                                            <\/option>\n                                            <option value=\"+47\">\n                                              +47 NO\n                                            <\/option>\n                                            <option value=\"+968\">\n                                              +968 OM\n                                            <\/option>\n                                            <option value=\"+92\">\n                                              +92 PK\n                                            <\/option>\n                                            <option value=\"+680\">\n                                              +680 PW\n                                            <\/option>\n                                            <option value=\"+970\">\n                                              +970 PS\n                                            <\/option>\n                                            <option value=\"+507\">\n                                              +507 PA\n                                            <\/option>\n                                            <option value=\"+675\">\n                                              +675 PG\n                                            <\/option>\n                                            <option value=\"+595\">\n                                              +595 PY\n                                            <\/option>\n                                            <option value=\"+51\">\n                                              +51 PE\n                                            <\/option>\n                                            <option value=\"+63\">\n                                              +63 PH\n                                            <\/option>\n                                            <option value=\"+64\">\n                                              +64 PN\n                                            <\/option>\n                                            <option value=\"+48\">\n                                              +48 PL\n                                            <\/option>\n                                            <option value=\"+351\">\n                                              +351 PT\n                                            <\/option>\n                                            <option value=\"+1787\">\n                                              +1787 PR\n                                            <\/option>\n                                            <option value=\"+974\">\n                                              +974 QA\n                                            <\/option>\n                                            <option value=\"+383\">\n                                              +383 XK\n                                            <\/option>\n                                            <option value=\"+262\">\n                                              +262 RE\n                                            <\/option>\n                                            <option value=\"+40\">\n                                              +40 RO\n                                            <\/option>\n                                            <option value=\"+7\">\n                                              +7 RU\n                                            <\/option>\n                                            <option value=\"+250\">\n                                              +250 RW\n                                            <\/option>\n                                            <option value=\"+590\">\n                                              +590 BL\n                                            <\/option>\n                                            <option value=\"+290\">\n                                              +290 SH\n                                            <\/option>\n                                            <option value=\"+1869\">\n                                              +1869 KN\n                                            <\/option>\n                                            <option value=\"+1758\">\n                                              +1758 LC\n                                            <\/option>\n                                            <option value=\"+590\">\n                                              +590 MF\n                                            <\/option>\n                                            <option value=\"+508\">\n                                              +508 PM\n                                            <\/option>\n                                            <option value=\"+1784\">\n                                              +1784 VC\n                                            <\/option>\n                                            <option value=\"+685\">\n                                              +685 WS\n                                            <\/option>\n                                            <option value=\"+378\">\n                                              +378 SM\n                                            <\/option>\n                                            <option value=\"+239\">\n                                              +239 ST\n                                            <\/option>\n                                            <option value=\"+966\">\n                                              +966 SA\n                                            <\/option>\n                                            <option value=\"+221\">\n                                              +221 SN\n                                            <\/option>\n                                            <option value=\"+381\">\n                                              +381 RS\n                                            <\/option>\n                                            <option value=\"+248\">\n                                              +248 SC\n                                            <\/option>\n                                            <option value=\"+232\">\n                                              +232 SL\n                                            <\/option>\n                                            <option value=\"+65\">\n                                              +65 SG\n                                            <\/option>\n                                            <option value=\"+1721\">\n                                              +1721 SX\n                                            <\/option>\n                                            <option value=\"+421\">\n                                              +421 SK\n                                            <\/option>\n                                            <option value=\"+386\">\n                                              +386 SI\n                                            <\/option>\n                                            <option value=\"+677\">\n                                              +677 SB\n                                            <\/option>\n                                            <option value=\"+252\">\n                                              +252 SO\n                                            <\/option>\n                                            <option value=\"+27\">\n                                              +27 ZA\n                                            <\/option>\n                                            <option value=\"+500\">\n                                              +500 GS\n                                            <\/option>\n                                            <option value=\"+211\">\n                                              +211 SS\n                                            <\/option>\n                                            <option value=\"+34\">\n                                              +34 ES\n                                            <\/option>\n                                            <option value=\"+94\">\n                                              +94 LK\n                                            <\/option>\n                                            <option value=\"+249\">\n                                              +249 SD\n                                            <\/option>\n                                            <option value=\"+597\">\n                                              +597 SR\n                                            <\/option>\n                                            <option value=\"+47\">\n                                              +47 SJ\n                                            <\/option>\n                                            <option value=\"+268\">\n                                              +268 SZ\n                                            <\/option>\n                                            <option value=\"+46\">\n                                              +46 SE\n                                            <\/option>\n                                            <option value=\"+41\">\n                                              +41 CH\n                                            <\/option>\n                                            <option value=\"+963\">\n                                              +963 SY\n                                            <\/option>\n                                            <option value=\"+886\">\n                                              +886 TW\n                                            <\/option>\n                                            <option value=\"+992\">\n                                              +992 TJ\n                                            <\/option>\n                                            <option value=\"+255\">\n                                              +255 TZ\n                                            <\/option>\n                                            <option value=\"+66\">\n                                              +66 TH\n                                            <\/option>\n                                            <option value=\"+670\">\n                                              +670 TL\n                                            <\/option>\n                                            <option value=\"+228\">\n                                              +228 TG\n                                            <\/option>\n                                            <option value=\"+690\">\n                                              +690 TK\n                                            <\/option>\n                                            <option value=\"+676\">\n                                              +676 TO\n                                            <\/option>\n                                            <option value=\"+1868\">\n                                              +1868 TT\n                                            <\/option>\n                                            <option value=\"+216\">\n                                              +216 TN\n                                            <\/option>\n                                            <option value=\"+90\">\n                                              +90 TR\n                                            <\/option>\n                                            <option value=\"+993\">\n                                              +993 TM\n                                            <\/option>\n                                            <option value=\"+1649\">\n                                              +1649 TC\n                                            <\/option>\n                                            <option value=\"+688\">\n                                              +688 TV\n                                            <\/option>\n                                            <option value=\"+256\">\n                                              +256 UG\n                                            <\/option>\n                                            <option value=\"+380\">\n                                              +380 UA\n                                            <\/option>\n                                            <option value=\"+971\">\n                                              +971 AE\n                                            <\/option>\n                                            <option value=\"+44\">\n                                              +44 GB\n                                            <\/option>\n                                            <option value=\"+1\">\n                                              +1 US\n                                            <\/option>\n                                            <option value=\"+246\">\n                                              +246 UM\n                                            <\/option>\n                                            <option value=\"+598\">\n                                              +598 UY\n                                            <\/option>\n                                            <option value=\"+998\">\n                                              +998 UZ\n                                            <\/option>\n                                            <option value=\"+678\">\n                                              +678 VU\n                                            <\/option>\n                                            <option value=\"+58\">\n                                              +58 VE\n                                            <\/option>\n                                            <option value=\"+84\">\n                                              +84 VN\n                                            <\/option>\n                                            <option value=\"+1284\">\n                                              +1284 VG\n                                            <\/option>\n                                            <option value=\"+1340\">\n                                              +1340 VI\n                                            <\/option>\n                                            <option value=\"+681\">\n                                              +681 WF\n                                            <\/option>\n                                            <option value=\"+212\">\n                                              +212 EH\n                                            <\/option>\n                                            <option value=\"+967\">\n                                              +967 YE\n                                            <\/option>\n                                            <option value=\"+260\">\n                                              +260 ZM\n                                            <\/option>\n                                            <option value=\"+263\">\n                                              +263 ZW\n                                            <\/option>\n                                          <\/select>\n                                        <\/div>\n                                        <div class=\"entry__field\" style=\"width: 100%\">\n                                          <input type=\"tel\" class=\"input\" id=\"SMS\" name=\"SMS\" autocomplete=\"off\" placeholder=\"SMS\">\n                                        <\/div>\n                                      <\/div>\n                                      <div class=\"sib-sms-tooltip\">\n                                        <div class=\"sib-sms-tooltip__box\">\n                                          Le champ SMS doit contenir entre 6 et 19 chiffres et inclure le code pays sans utiliser +\/0 (ex. : 33xxxxxxxxx pour la France)\n                                        <\/div>\n                                        <span class=\"sib-sms-tooltip__icon\">?<\/span>\n                                      <\/div>\n                                    <\/div>\n                                  <\/div>\n\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__error entry__error--secondary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-input sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"DATE_DE_NAISSANCE_FORMAT\">Entrez votre DATE_DE_NAISSANCE_FORMAT<\/label>\n\n                                    <div class=\"entry__field\">\n                                      <input class=\"input \" maxlength=\"200\" type=\"text\" id=\"DATE_DE_NAISSANCE_FORMAT\" name=\"DATE_DE_NAISSANCE_FORMAT\" autocomplete=\"off\" placeholder=\"DATE_DE_NAISSANCE_FORMAT\">\n                                    <\/div>\n                                  <\/div>\n\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-input sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"AGE\">Entrez votre AGE<\/label>\n                                    <div class=\"entry__field\">\n                                      <input maxlength=\"200\" type=\"text\" data-numeric=\"true\" class=\"input \" id=\"AGE\" name=\"AGE\" autocomplete=\"off\" placeholder=\"AGE\">\n                                    <\/div>\n                                  <\/div>\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-input sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"ADRESSE\" data-required=\"*\">Entrez votre ADRESSE<\/label>\n\n                                    <div class=\"entry__field\">\n                                      <input class=\"input \" maxlength=\"200\" type=\"text\" id=\"ADRESSE\" name=\"ADRESSE\" autocomplete=\"off\" placeholder=\"ADRESSE\" data-required=\"true\" required=\"\">\n                                    <\/div>\n                                  <\/div>\n\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"VILLE\" data-required=\"*\">Quelle est votre ville ?<\/label>\n                                    <div class=\"entry__field\">\n                                      <select class=\"input\" id=\"VILLE\" name=\"VILLE\" data-required=\"true\">\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\n\n                                        <option class=\"sib-menu__item\" value=\"1\">\n                                          AUPS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"2\">\n                                          AIGUINES\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"3\">\n                                          DRAGUIGNAN\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"4\">\n                                          LES ARCS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"5\">\n                                          VIDAUBAN\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"6\">\n                                          FLAYOSC\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"7\">\n                                          AUTRE\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"8\">\n                                          ARTIGNOSC\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"9\">\n                                          SALERNES\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"10\">\n                                          LORGUES\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"11\">\n                                          SAINT ANTONIN\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"12\">\n                                          TOURTOUR\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"13\">\n                                          VILLECROZE\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"14\">\n                                          BAUDUEN\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"15\">\n                                          COMPS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"16\">\n                                          LA-MOTTE\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"17\">\n                                          LE-MUY\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"18\">\n                                          LES-ARCS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"19\">\n                                          TRANS-EN-PROVENCE\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"20\">\n                                          BARGEMON\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"21\">\n                                          CALLAS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"22\">\n                                          BARGEME\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"23\">\n                                          CLAVIER\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"24\">\n                                          FIGANIERES\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"25\">\n                                          AMPUS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"26\">\n                                          MONTFERRAT\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"27\">\n                                          REGUSSE\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"28\">\n                                          FOX AMPHOUX\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"29\">\n                                          LES-SALLES-SUR-VERDON\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"30\">\n                                          BAUDINARD\n                                        <\/option>\n                                      <\/select>\n                                    <\/div>\n                                  <\/div>\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-form-block sib-image-form-block\" style=\"text-align: center\">\n                                <img decoding=\"async\" src=\"https:\/\/img.mailinblue.com\/7825646\/images\/content_library\/original\/667eab3ae9fc6934ca847223.png\" style=\"width: 500px;height: 470px;\" alt=\"SECTEUR\" title=\"SECTEUR\">\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"DROIT\" data-required=\"*\">Quelle est votre couverture sociale ?<\/label>\n                                    <div class=\"entry__field\">\n                                      <select class=\"input\" id=\"DROIT\" name=\"DROIT\" data-required=\"true\">\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\n\n                                        <option class=\"sib-menu__item\" value=\"1\">\n                                          ALD\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"2\">\n                                          CSS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"3\">\n                                          MUTUELLE\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"4\">\n                                          PAS DE DROIT\n                                        <\/option>\n                                      <\/select>\n                                    <\/div>\n                                  <\/div>\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"MEDTRAITANT\" data-required=\"*\">Avez vous un m\u00e9decin traitant?<\/label>\n                                    <div class=\"entry__field\">\n                                      <select class=\"input\" id=\"MEDTRAITANT\" name=\"MEDTRAITANT\" data-required=\"true\">\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\n\n                                        <option class=\"sib-menu__item\" value=\"1\">\n                                          OUI ici\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"2\">\n                                          OUI mais dans une autre r\u00e9gion\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"3\">\n                                          NON, depuis peu ( moins d&rsquo;un an)\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"4\">\n                                          NON, depuis longtemps\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"5\">\n                                          NON j&rsquo;en ai jamais eu\n                                        <\/option>\n                                      <\/select>\n                                    <\/div>\n                                  <\/div>\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"DEPLACEMENT\" data-required=\"*\">Pouvez vous d\u00e9placer pour la consultation m\u00e9dicale ?<\/label>\n                                    <div class=\"entry__field\">\n                                      <select class=\"input\" id=\"DEPLACEMENT\" name=\"DEPLACEMENT\" data-required=\"true\">\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\n\n                                        <option class=\"sib-menu__item\" value=\"1\">\n                                          EN CABINET\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"2\">\n                                          EN CABINET ACCOMPAGNE(E) OU TAXI\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"3\">\n                                          UNIQUEMENT VISITE A DOMICILE\n                                        <\/option>\n                                      <\/select>\n                                    <\/div>\n                                  <\/div>\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-select sib-form-block\">\n                                <div class=\"form__entry entry_block\">\n                                  <div class=\"form__label-row \">\n                                    <label class=\"entry__label\" style=\"font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#3c4858;\" for=\"PARTENAIRES\">Si cette demande vient d&rsquo;un partenaire merci de nous pr\u00e9ciser<\/label>\n                                    <div class=\"entry__field\">\n                                      <select class=\"input\" id=\"PARTENAIRES\" name=\"PARTENAIRES\">\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\n\n                                        <option class=\"sib-menu__item\" value=\"1\">\n                                          DAC\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"2\">\n                                          CCAS\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"3\">\n                                          CHD\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"4\">\n                                          PND\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"5\">\n                                          AUTRE\n                                        <\/option>\n                                        <option class=\"sib-menu__item\" value=\"6\">\n                                          MISAS\/MAS\n                                        <\/option>\n                                      <\/select>\n                                    <\/div>\n                                  <\/div>\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-optin sib-form-block\">\n                                <div class=\"form__entry entry_mcq\">\n                                  <div class=\"form__label-row \">\n                                    <div class=\"entry__choice\" style=\"\">\n                                      <label>\n                                        <input type=\"checkbox\" class=\"input_replaced\" value=\"1\" id=\"OPT_IN\" name=\"OPT_IN\">\n                                        <span class=\"checkbox checkbox_tick_positive\" style=\"margin-left:\"><\/span><span style=\"font-size:14px; text-align:left; font-family:Helvetica, sans-serif; color:#3C4858; background-color:transparent;\"><p>J&rsquo;accepte de recevoir vos e-mails et confirme avoir pris connaissance de votre politique de confidentialit\u00e9 et mentions l\u00e9gales.<\/p><\/span>                                        <\/label>\n                                    <\/div>\n                                  <\/div>\n                                  <label class=\"entry__error entry__error--primary\" style=\"font-size:16px; text-align:left; font-family:Helvetica, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;\">\n                                  <\/label>\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\n                                    Vous pouvez vous d\u00e9sinscrire \u00e0 tout moment en cliquant sur le lien pr\u00e9sent dans nos emails.\n                                  <\/label>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-form__declaration\" style=\"direction:ltr\">\n                                <div class=\"declaration-block-icon\">\n                                  <svg class=\"icon__SVG\" width=\"0\" height=\"0\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\n                                    <defs>\n                                      <symbol id=\"svgIcon-sphere\" viewBox=\"0 0 63 63\">\n                                        <path class=\"path1\" d=\"M31.54 0l1.05 3.06 3.385-.01-2.735 1.897 1.05 3.042-2.748-1.886-2.738 1.886 1.044-3.05-2.745-1.897h3.393zm13.97 3.019L46.555 6.4l3.384.01-2.743 2.101 1.048 3.387-2.752-2.1-2.752 2.1 1.054-3.382-2.745-2.105h3.385zm9.998 10.056l1.039 3.382h3.38l-2.751 2.1 1.05 3.382-2.744-2.091-2.743 2.091 1.054-3.381-2.754-2.1h3.385zM58.58 27.1l1.04 3.372h3.379l-2.752 2.096 1.05 3.387-2.744-2.091-2.75 2.092 1.054-3.387-2.747-2.097h3.376zm-3.076 14.02l1.044 3.364h3.385l-2.743 2.09 1.05 3.392-2.744-2.097-2.743 2.097 1.052-3.377-2.752-2.117 3.385-.01zm-9.985 9.91l1.045 3.364h3.393l-2.752 2.09 1.05 3.393-2.745-2.097-2.743 2.097 1.05-3.383-2.751-2.1 3.384-.01zM31.45 55.01l1.044 3.043 3.393-.008-2.752 1.9L34.19 63l-2.744-1.895-2.748 1.891 1.054-3.05-2.743-1.9h3.384zm-13.934-3.98l1.036 3.364h3.402l-2.752 2.09 1.053 3.393-2.747-2.097-2.752 2.097 1.053-3.382-2.743-2.1 3.384-.01zm-9.981-9.91l1.045 3.364h3.398l-2.748 2.09 1.05 3.392-2.753-2.1-2.752 2.096 1.053-3.382-2.743-2.102 3.384-.009zM4.466 27.1l1.038 3.372H8.88l-2.752 2.097 1.053 3.387-2.743-2.09-2.748 2.09 1.053-3.387L0 30.472h3.385zm3.069-14.025l1.045 3.382h3.395L9.23 18.56l1.05 3.381-2.752-2.09-2.752 2.09 1.053-3.381-2.744-2.1h3.384zm9.99-10.056L18.57 6.4l3.393.01-2.743 2.1 1.05 3.373-2.754-2.092-2.751 2.092 1.053-3.382-2.744-2.1h3.384zm24.938 19.394l-10-4.22a2.48 2.48 0 00-1.921 0l-10 4.22A2.529 2.529 0 0019 24.75c0 10.47 5.964 17.705 11.537 20.057a2.48 2.48 0 001.921 0C36.921 42.924 44 36.421 44 24.75a2.532 2.532 0 00-1.537-2.336zm-2.46 6.023l-9.583 9.705a.83.83 0 01-1.177 0l-5.416-5.485a.855.855 0 010-1.192l1.177-1.192a.83.83 0 011.177 0l3.65 3.697 7.819-7.916a.83.83 0 011.177 0l1.177 1.191a.843.843 0 010 1.192z\"\n                                          fill=\"#0092FF\"><\/path>\n                                      <\/symbol>\n                                    <\/defs>\n                                  <\/svg>\n                                  <svg class=\"svgIcon-sphere\" style=\"width:63px; height:63px;\">\n                                    <use xlink:href=\"#svgIcon-sphere\"><\/use>\n                                  <\/svg>\n                                <\/div>\n                                <div style=\"font-size:14px; text-align:left; font-family:Helvetica, sans-serif; color:#687484; background-color:transparent;\">\n                                  <p>Nous utilisons Brevo en tant que plateforme marketing. En soumettant ce formulaire, vous acceptez que les donn\u00e9es personnelles que vous avez fournies soient transf\u00e9r\u00e9es \u00e0 Brevo pour \u00eatre trait\u00e9es conform\u00e9ment\n                                    <a target=\"_blank\"\n                                      href=\"https:\/\/www.brevo.com\/fr\/legal\/privacypolicy\/\">\u00e0 la politique de confidentialit\u00e9 de Brevo.<\/a>\n                                  <\/p>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                            <div style=\"padding: 8px 0;\">\n                              <div class=\"sib-form-block\" style=\"text-align: left\">\n                                <button class=\"sib-form-block__button sib-form-block__button-with-loader\" style=\"font-size:16px; text-align:left; font-weight:700; font-family:Helvetica, sans-serif; color:#FFFFFF; background-color:#3E4857; border-radius:3px; border-width:0px;\" form=\"sib-form\"\n                                  type=\"submit\">\n                                  <svg class=\"icon clickable__icon progress-indicator__icon sib-hide-loader-icon\" viewBox=\"0 0 512 512\" style=\"\">\n                                    <path d=\"M460.116 373.846l-20.823-12.022c-5.541-3.199-7.54-10.159-4.663-15.874 30.137-59.886 28.343-131.652-5.386-189.946-33.641-58.394-94.896-95.833-161.827-99.676C261.028 55.961 256 50.751 256 44.352V20.309c0-6.904 5.808-12.337 12.703-11.982 83.556 4.306 160.163 50.864 202.11 123.677 42.063 72.696 44.079 162.316 6.031 236.832-3.14 6.148-10.75 8.461-16.728 5.01z\"><\/path>\n                                  <\/svg>\n                                  VALIDER\n                                <\/button>\n                              <\/div>\n                            <\/div>\n\n                            <input type=\"text\" name=\"email_address_check\" value=\"\" class=\"input--hidden\">\n                            <input type=\"hidden\" name=\"locale\" value=\"fr\">\n                          <\/form>\n                        <\/div>\n                      <\/div>\n                    <\/div>\n                    <!-- END - We recommend to place the above code where you want the form in your website html  -->\n\n                    <!-- START - We recommend to place the below code in footer or bottom of your website html  -->\n                    <script>\n                      window.REQUIRED_CODE_ERROR_MESSAGE = 'Veuillez choisir un code pays';\n                      window.LOCALE = 'fr';\n                      window.EMAIL_INVALID_MESSAGE = window.SMS_INVALID_MESSAGE = \"Les informations que vous avez fournies ne sont pas valides. Veuillez v\u00e9rifier le format du champ et r\u00e9essayer.\";\n\n                      window.REQUIRED_ERROR_MESSAGE = \"Vous devez renseigner ce champ. \";\n\n                      window.GENERIC_INVALID_MESSAGE = \"Les informations que vous avez fournies ne sont pas valides. Veuillez v\u00e9rifier le format du champ et r\u00e9essayer.\";\n\n                      window.INVALID_NUMBER = \"Les informations que vous avez fournies ne sont pas valides. Veuillez v\u00e9rifier le format du champ et r\u00e9essayer.\";\n\n\n\n                      window.translation = {\n                        common: {\n                          selectedList: '{quantity} liste s\u00e9lectionn\u00e9e',\n                          selectedLists: '{quantity} listes s\u00e9lectionn\u00e9es',\n                          selectedOption: '{quantity} s\u00e9lectionn\u00e9',\n                          selectedOptions: '{quantity} s\u00e9lectionn\u00e9s',\n                        }\n                      };\n\n                      var AUTOHIDE = Boolean(0);\n                    <\/script>\n\n                    <script defer=\"\" src=\"https:\/\/sibforms.com\/forms\/end-form\/build\/main.js\"><\/script>\n\n\n                    <!-- END - We recommend to place the above code in footer or bottom of your website html  -->\n                    <!-- End Brevo Form -->\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c27\" id=\"portfolio\" class=\"h-section h-section-global-spacing d-flex align-items-lg-center align-items-md-center align-items-center style-3493 style-local-3093-c27 position-relative\">\n    <!---->\n    <!---->\n    <div class=\"h-section-grid-container h-section-boxed-container\">\n      <!---->\n      <div data-colibri-id=\"3093-c28\" class=\"h-row-container gutters-row-lg-2 gutters-row-md-2 gutters-row-0 gutters-row-v-lg-2 gutters-row-v-md-2 gutters-row-v-2 style-3494 style-local-3093-c28 position-relative\">\n        <!---->\n        <div class=\"h-row justify-content-lg-center justify-content-md-center justify-content-center align-items-lg-stretch align-items-md-stretch align-items-stretch gutters-col-lg-2 gutters-col-md-2 gutters-col-0 gutters-col-v-lg-2 gutters-col-v-md-2 gutters-col-v-2\">\n          <!---->\n          <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-3495-outer style-local-3093-c29-outer\">\n            <div data-colibri-id=\"3093-c29\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-0 h-px-md-0 h-px-0 v-inner-lg-0 v-inner-md-0 v-inner-0 style-3495 style-local-3093-c29 position-relative\">\n              <div class=\"background-wrapper\">\n                <div class=\"background-layer background-layer-media-container-lg\">\n                  <!---->\n                  <div class=\"overlay-layer\">\n                    <div class=\"overlay-image-layer\" style=\"background-color: rgb(255, 255, 255); opacity: 0.8;\"><\/div>\n                  <\/div>\n                <\/div>\n                <div class=\"background-layer background-layer-media-container-md\">\n                  <!---->\n                  <div class=\"overlay-layer\">\n                    <div class=\"overlay-image-layer\" style=\"background-color: rgb(255, 255, 255); opacity: 0.8;\"><\/div>\n                  <\/div>\n                <\/div>\n                <div class=\"background-layer background-layer-media-container\">\n                  <!---->\n                  <div class=\"overlay-layer\">\n                    <div class=\"overlay-image-layer\" style=\"background-color: rgb(255, 255, 255); opacity: 0.8;\"><\/div>\n                  <\/div>\n                <\/div>\n              <\/div>\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                <!---->\n                <div data-colibri-id=\"3093-c30\" class=\"h-global-transition-all h-heading style-3496 style-local-3093-c30 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-heading__outer style-3496 style-local-3093-c30\">\n                    <!---->\n                    <!---->\n                    <h3 class=\"\"><span style=\"font-weight: 400;\">R\u00e9alisez votre bilan de pr\u00e9vention pour fluidifier votre orientation<\/span><\/h3>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c31\" class=\"h-text h-text-component style-3497 style-local-3093-c31 position-relative h-element\">\n                  <!---->\n                  <!---->\n                  <div class=\"\">\n                    <p>Afin de mieux comprendre votre dossier et de vous orienter vers un m\u00e9decin traitant, nous vous conseillons de r\u00e9aliser votre bilan de pr\u00e9vention en amont. <\/p>\n                  <\/div>\n                <\/div>\n                <div data-colibri-id=\"3093-c32\" class=\"h-x-container style-3498 style-local-3093-c32 position-relative h-element\">\n                  <!---->\n                  <div class=\"h-x-container-inner style-dynamic-3093-c32-group style-3498-spacing style-local-3093-c32-spacing\"><span class=\"h-button__outer style-3499-outer style-local-3093-c33-outer d-inline-flex h-element\"><a h-use-smooth-scroll=\"true\" href=\"https:\/\/www.doctolib.fr\/etablissement-de-prevention\/draguignan\/centre-de-prevention-en-sante-de-la-dracenie\"  data-colibri-id=\"3093-c33\" class=\"d-flex w-100 align-items-center h-button justify-content-lg-center justify-content-md-center justify-content-center style-3499 style-local-3093-c33 position-relative\"><!----><!----> <span>RDV bilan de pr\u00e9vention -GRATUIT-<\/span><\/a>\n                    <\/span><span class=\"h-button__outer style-3518-outer style-local-3093-c34-outer d-inline-flex h-element\"><a h-use-smooth-scroll=\"true\" href=\"https:\/\/centrepreventiondracenie.fr\/\"  data-colibri-id=\"3093-c34\" class=\"d-flex w-100 align-items-center h-button justify-content-lg-center justify-content-md-center justify-content-center style-3518 style-local-3093-c34 position-relative\"><!----><!----> <span>Plus d&rsquo;informations<\/span><\/a>\n                    <\/span>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n          <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-3500-outer style-local-3093-c35-outer\">\n            <div data-colibri-id=\"3093-c35\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-0 h-px-md-0 h-px-0 v-inner-lg-0 v-inner-md-0 v-inner-0 style-3500 style-local-3093-c35 position-relative\">\n              <!---->\n              <!---->\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                <!---->\n                <div data-colibri-id=\"3093-c36\" class=\"h-row-container gutters-row-lg-1 gutters-row-md-1 gutters-row-0 gutters-row-v-lg-1 gutters-row-v-md-1 gutters-row-v-1 style-3501 style-local-3093-c36 position-relative\">\n                  <!---->\n                  <div class=\"h-row justify-content-lg-center justify-content-md-center justify-content-center align-items-lg-stretch align-items-md-stretch align-items-stretch gutters-col-lg-1 gutters-col-md-1 gutters-col-0 gutters-col-v-lg-1 gutters-col-v-md-1 gutters-col-v-1\">\n                    <!---->\n                    <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-3502-outer style-local-3093-c37-outer\">\n                      <div data-colibri-id=\"3093-c37\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-0 h-px-md-0 h-px-0 v-inner-lg-0 v-inner-md-0 v-inner-0 style-3502 style-local-3093-c37 position-relative\">\n                        <div class=\"background-wrapper\">\n                          <div class=\"background-layer background-layer-media-container-lg\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container-md\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                        <!---->\n                        <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                          <!---->\n                          <div data-colibri-id=\"3093-c38\" class=\"h-global-transition-all h-heading style-3505 style-local-3093-c38 position-relative h-element\">\n                            <!---->\n                            <div class=\"h-heading__outer style-3505 style-local-3093-c38\">\n                              <!---->\n                              <!---->\n                              <h5 class=\"\">18-25 ans<\/h5>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                      <\/div>\n                    <\/div>\n                    <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-3508-outer style-local-3093-c39-outer\">\n                      <div data-colibri-id=\"3093-c39\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-0 h-px-md-0 h-px-0 v-inner-lg-0 v-inner-md-0 v-inner-0 style-3508 style-local-3093-c39 position-relative\">\n                        <div class=\"background-wrapper\">\n                          <div class=\"background-layer background-layer-media-container-lg\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container-md\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                        <!---->\n                        <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                          <!---->\n                          <div data-colibri-component=\"content-swap\" data-colibri-id=\"3093-c40\" class=\"content-swap style-3509 style-local-3093-c40 position-relative h-element\">\n                            <!---->\n                            <div class=\"d-flex position-relative border-radius-inherit h-content-swap__overflow\">\n                              <div data-normal=\"\" data-colibri-id=\"3093-c41\" class=\"h-content-swap__normal d-flex border-radius-inherit hide-animation style-3504 style-local-3093-c41 position-relative\">\n                                <!---->\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\n                                  <!---->\n                                  <div data-colibri-id=\"3093-c42\" class=\"h-global-transition-all h-heading style-3505 style-local-3093-c42 position-relative h-element\">\n                                    <!---->\n                                    <div class=\"h-heading__outer style-3505 style-local-3093-c42\">\n                                      <!---->\n                                      <!---->\n                                      <h5 class=\"\">45-50 ans<\/h5>\n                                    <\/div>\n                                  <\/div>\n                                <\/div>\n                              <\/div>\n                              <div data-hover=\"\" data-colibri-component=\"link\" data-href=\"\" data-colibri-id=\"3093-c43\" class=\"h-content-swap-hover-container animated h-content-swap__hover d-flex border-radius-inherit fadeIn justify-content-lg-center justify-content-md-center justify-content-center style-3506 style-local-3093-c43 position-relative\"\n                                style=\"display: none;\">\n                                <!---->\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\n                                  <!---->\n                                  <div data-colibri-id=\"3093-c44\" class=\"h-icon style-3507 style-local-3093-c44 position-relative h-element\">\n                                    <!---->\n                                    <a href=\"#\" h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-3507-icon style-local-3093-c44-icon\"><!--Icon by Icons8 Line Awesome (https:\/\/icons8.com\/line-awesome)--><svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" id=\"search\" viewBox=\"0 0 512 545.5\"><path d=\"M304 80c88.176 0 160 71.824 160 160s-71.824 160-160 160c-38.32 0-73.41-13.423-101-36L75.5 491.5l-23-23L180 341c-22.577-27.59-36-62.68-36-101 0-88.176 71.824-160 160-160zm0 32c-70.882 0-128 57.118-128 128s57.118 128 128 128 128-57.118 128-128-57.118-128-128-128z\"><\/path><\/svg><\/span><\/a>\n                                  <\/div>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                      <\/div>\n                    <\/div>\n                    <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-3510-outer style-local-3093-c45-outer\">\n                      <div data-colibri-id=\"3093-c45\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-0 h-px-md-0 h-px-0 v-inner-lg-0 v-inner-md-0 v-inner-0 style-3510 style-local-3093-c45 position-relative\">\n                        <div class=\"background-wrapper\">\n                          <div class=\"background-layer background-layer-media-container-lg\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container-md\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                        <!---->\n                        <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                          <!---->\n                          <div data-colibri-component=\"content-swap\" data-colibri-id=\"3093-c46\" class=\"content-swap style-3511 style-local-3093-c46 position-relative h-element\">\n                            <!---->\n                            <div class=\"d-flex position-relative border-radius-inherit h-content-swap__overflow\">\n                              <div data-normal=\"\" data-colibri-id=\"3093-c47\" class=\"h-content-swap__normal d-flex border-radius-inherit hide-animation style-3504 style-local-3093-c47 position-relative\">\n                                <!---->\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\n                                  <!---->\n                                  <div data-colibri-id=\"3093-c48\" class=\"h-global-transition-all h-heading style-3505 style-local-3093-c48 position-relative h-element\">\n                                    <!---->\n                                    <div class=\"h-heading__outer style-3505 style-local-3093-c48\">\n                                      <!---->\n                                      <!---->\n                                      <h5 class=\"\">60-65 ans<\/h5>\n                                    <\/div>\n                                  <\/div>\n                                <\/div>\n                              <\/div>\n                              <div data-hover=\"\" data-colibri-component=\"link\" data-href=\"\" data-colibri-id=\"3093-c49\" class=\"h-content-swap-hover-container animated h-content-swap__hover d-flex border-radius-inherit fadeIn justify-content-lg-center justify-content-md-center justify-content-center style-3506 style-local-3093-c49 position-relative\"\n                                style=\"display: none;\">\n                                <!---->\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\n                                  <!---->\n                                  <div data-colibri-id=\"3093-c50\" class=\"h-icon style-3507 style-local-3093-c50 position-relative h-element\">\n                                    <!---->\n                                    <a href=\"#\" h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-3507-icon style-local-3093-c50-icon\"><!--Icon by Icons8 Line Awesome (https:\/\/icons8.com\/line-awesome)--><svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" id=\"search\" viewBox=\"0 0 512 545.5\"><path d=\"M304 80c88.176 0 160 71.824 160 160s-71.824 160-160 160c-38.32 0-73.41-13.423-101-36L75.5 491.5l-23-23L180 341c-22.577-27.59-36-62.68-36-101 0-88.176 71.824-160 160-160zm0 32c-70.882 0-128 57.118-128 128s57.118 128 128 128 128-57.118 128-128-57.118-128-128-128z\"><\/path><\/svg><\/span><\/a>\n                                  <\/div>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                      <\/div>\n                    <\/div>\n                    <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-3512-outer style-local-3093-c51-outer\">\n                      <div data-colibri-id=\"3093-c51\" class=\"d-flex h-flex-basis h-column__inner h-px-lg-0 h-px-md-0 h-px-0 v-inner-lg-0 v-inner-md-0 v-inner-0 style-3512 style-local-3093-c51 position-relative\">\n                        <div class=\"background-wrapper\">\n                          <div class=\"background-layer background-layer-media-container-lg\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container-md\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                          <div class=\"background-layer background-layer-media-container\">\n                            <!---->\n                            <div class=\"overlay-layer\">\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(75, 174, 243); opacity: 0.7;\"><\/div>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                        <!---->\n                        <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100 align-self-lg-center align-self-md-center align-self-center\">\n                          <!---->\n                          <div data-colibri-component=\"content-swap\" data-colibri-id=\"3093-c52\" class=\"content-swap style-3513 style-local-3093-c52 position-relative h-element\">\n                            <!---->\n                            <div class=\"d-flex position-relative border-radius-inherit h-content-swap__overflow\">\n                              <div data-normal=\"\" data-colibri-id=\"3093-c53\" class=\"h-content-swap__normal d-flex border-radius-inherit hide-animation style-3504 style-local-3093-c53 position-relative\">\n                                <!---->\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\n                                  <!---->\n                                  <div data-colibri-id=\"3093-c54\" class=\"h-global-transition-all h-heading style-3505 style-local-3093-c54 position-relative h-element\">\n                                    <!---->\n                                    <div class=\"h-heading__outer style-3505 style-local-3093-c54\">\n                                      <!---->\n                                      <!---->\n                                      <h5 class=\"\">70-75 ans<\/h5>\n                                    <\/div>\n                                  <\/div>\n                                <\/div>\n                              <\/div>\n                              <div data-hover=\"\" data-colibri-component=\"link\" data-href=\"\" data-colibri-id=\"3093-c55\" class=\"h-content-swap-hover-container animated h-content-swap__hover d-flex border-radius-inherit fadeIn justify-content-lg-center justify-content-md-center justify-content-center style-3506 style-local-3093-c55 position-relative\"\n                                style=\"display: none;\">\n                                <!---->\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\n                                  <!---->\n                                  <div data-colibri-id=\"3093-c56\" class=\"h-icon style-3507 style-local-3093-c56 position-relative h-element\">\n                                    <!---->\n                                    <a href=\"#\" h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-3507-icon style-local-3093-c56-icon\"><!--Icon by Icons8 Line Awesome (https:\/\/icons8.com\/line-awesome)--><svg version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" id=\"search\" viewBox=\"0 0 512 545.5\"><path d=\"M304 80c88.176 0 160 71.824 160 160s-71.824 160-160 160c-38.32 0-73.41-13.423-101-36L75.5 491.5l-23-23L180 341c-22.577-27.59-36-62.68-36-101 0-88.176 71.824-160 160-160zm0 32c-70.882 0-128 57.118-128 128s57.118 128 128 128 128-57.118 128-128-57.118-128-128-128z\"><\/path><\/svg><\/span><\/a>\n                                  <\/div>\n                                <\/div>\n                              <\/div>\n                            <\/div>\n                          <\/div>\n                        <\/div>\n                      <\/div>\n                    <\/div>\n                  <\/div>\n                <\/div>\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>Vous recherchez un m\u00e9decin traitant? Avez vous pensez \u00e0 demander \u00e0 votre sp\u00e9cialiste de vous d\u00e9clarer ? Pour les oins ponctuels des m\u00e9decins g\u00e9n\u00e9ralistes assurent des consultations ponctuelles et le suivi de votre pathologie est r\u00e9alis\u00e9 par votre sp\u00e9cialiste. Besoin d&rsquo;un certificat ou dossier et vous n&rsquo;avez pas de m\u00e9decin traitant? Selon votre localisation Nous [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":94,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"page-templates\/full-width-page.php","meta":{"footnotes":""},"class_list":["post-3093","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Formulaire de demande de m\u00e9decin traitant &#8211;<\/title>\n<meta name=\"description\" content=\"Formulaire a remplir en cas de recherche de m\u00e9decin traitant sur le territoire de la CPTS. 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Celui ci renseigne votre identit\u00e9 et vos droits.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/cptsdracenie.fr\/index.php\/mission-de-sante\/acces-aux-medecins\/formulaire-de-demande-de-medecin-traitant\/\" \/>\n<meta property=\"og:site_name\" content=\"Communaut\u00e9 Professionnelle Territoriale de Sant\u00e9 Drac\u00e9nie Provence Verdon\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/CPTSDPV\/\" \/>\n<meta property=\"article:modified_time\" content=\"2026-04-10T15:51:05+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/img.mailinblue.com\/7825646\/images\/content_library\/original\/667eab3ae9fc6934ca847223.png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Dur\u00e9e de lecture estim\u00e9e\" \/>\n\t<meta name=\"twitter:data1\" content=\"6 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/cptsdracenie.fr\\\/index.php\\\/mission-de-sante\\\/acces-aux-medecins\\\/formulaire-de-demande-de-medecin-traitant\\\/\",\"url\":\"https:\\\/\\\/cptsdracenie.fr\\\/index.php\\\/mission-de-sante\\\/acces-aux-medecins\\\/formulaire-de-demande-de-medecin-traitant\\\/\",\"name\":\"Formulaire de demande de m\u00e9decin traitant &#8211;\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/cptsdracenie.fr\\\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\\\/\\\/cptsdracenie.fr\\\/index.php\\\/mission-de-sante\\\/acces-aux-medecins\\\/formulaire-de-demande-de-medecin-traitant\\\/#primaryimage\"},\"image\":{\"@id\":\"https:\\\/\\\/cptsdracenie.fr\\\/index.php\\\/mission-de-sante\\\/acces-aux-medecins\\\/formulaire-de-demande-de-medecin-traitant\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/img.mailinblue.com\\\/7825646\\\/images\\\/content_library\\\/original\\\/667eab3ae9fc6934ca847223.png\",\"datePublished\":\"2022-08-17T12:00:09+00:00\",\"dateModified\":\"2026-04-10T15:51:05+00:00\",\"description\":\"Formulaire a remplir en cas de recherche de m\u00e9decin traitant sur le territoire de la CPTS. 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