{"id":3093,"date":"2022-08-17T14:00:09","date_gmt":"2022-08-17T12:00:09","guid":{"rendered":"https:\/\/cptsdracenie.fr\/?page_id=3093"},"modified":"2026-08-25T15:17:00","modified_gmt":"2026-08-25T13:17:00","slug":"formulaire-de-demande-de-medecin-traitant","status":"publish","type":"page","link":"https:\/\/cptsdracenie.fr\/index.php\/qui-somme-snous\/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\">\r\n  <!---->\r\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c2\" 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-c2 position-relative\">\r\n    <!---->\r\n    <!---->\r\n    <div class=\"h-section-grid-container h-section-boxed-container\">\r\n      <!---->\r\n      <div data-colibri-id=\"3093-c69\" 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-6273 style-local-3093-c69 position-relative\">\r\n        <!---->\r\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\">\r\n          <!---->\r\n          <div class=\"h-column h-column-container d-flex h-col-lg-auto h-col-md-auto h-col-auto style-6274-outer style-local-3093-c70-outer\">\r\n            <div data-colibri-id=\"3093-c70\" 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-6274 style-local-3093-c70 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c71\" class=\"style-6275 style-local-3093-c71 position-relative h-element\">\r\n                  <!---->\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\n        <\/div>\r\n      <\/div>\r\n      <div data-colibri-id=\"3093-c3\" 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-c3 position-relative\">\r\n        <!---->\r\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\">\r\n          <!---->\r\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-c4-outer\">\r\n            <div data-colibri-id=\"3093-c4\" 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-c4 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c5\" class=\"h-global-transition-all h-heading style-5460 style-local-3093-c5 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-heading__outer style-5460 style-local-3093-c5\">\r\n                    <!---->\r\n                    <!---->\r\n                    <h2 class=\"\">Vous recherchez un m\u00e9decin traitant?<\/h2>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c6\" class=\"h-text h-text-component style-5461 style-local-3093-c6 position-relative h-element\">\r\n                  <!---->\r\n                  <!---->\r\n                  <div class=\"\">\r\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>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c7\" class=\"h-x-container style-5463 style-local-3093-c7 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-x-container-inner style-dynamic-3093-c7-group style-5463-spacing style-local-3093-c7-spacing\"><span class=\"h-button__outer style-5464-outer style-local-3093-c8-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-c8\" 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-c8 position-relative\"><!----><!----> <span>Besoin d&rsquo;un certificat ou dossier et vous n&rsquo;avez pas de m\u00e9decin traitant?<\/span><\/a>\r\n                    <\/span>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\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-c9-outer\">\r\n            <div data-colibri-id=\"3093-c9\" 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-c9 position-relative\">\r\n              <!---->\r\n              <!---->\r\n              <div class=\"w-100 h-y-container h-column__content h-column__v-align flex-basis-100\">\r\n                <!---->\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\n        <\/div>\r\n      <\/div>\r\n    <\/div>\r\n  <\/div>\r\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c10\" 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-c10 position-relative\">\r\n    <!---->\r\n    <!---->\r\n    <div class=\"h-section-grid-container h-section-boxed-container\">\r\n      <!---->\r\n      <div data-colibri-id=\"3093-c11\" 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-c11 position-relative\">\r\n        <!---->\r\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\">\r\n          <!---->\r\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\">\r\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\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c13\" class=\"h-icon style-4552 style-local-3093-c13 position-relative h-element\">\r\n                  <!----><span class=\"h-svg-icon h-icon__icon style-4552-icon style-local-3093-c13-icon\"><!--Icon by Font Awesome (https:\/\/fontawesome.com)-->\r\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\">\r\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>\r\n    <\/svg><\/span><\/div>\r\n                <div data-colibri-id=\"3093-c14\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c14 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c14\">\r\n                    <!---->\r\n                    <!---->\r\n                    <h5 class=\"\">Selon votre localisation<\/h5>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c15\" class=\"h-text h-text-component style-4554 style-local-3093-c15 position-relative h-element\">\r\n                  <!---->\r\n                  <!---->\r\n                  <div class=\"\">\r\n                    <p>Nous ne traitons que les demandes de notre territoire<\/p>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\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-c16-outer\">\r\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-4551 style-local-3093-c16 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c17\" class=\"h-icon style-4552 style-local-3093-c17 position-relative h-element\">\r\n                  <!----><span class=\"h-svg-icon h-icon__icon style-4552-icon style-local-3093-c17-icon\"><!--Icon by Font Awesome (https:\/\/fontawesome.com)-->\r\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\">\r\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>\r\n    <\/svg><\/span><\/div>\r\n                <div data-colibri-id=\"3093-c18\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c18 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c18\">\r\n                    <!---->\r\n                    <!---->\r\n                    <h5 class=\"\">Nous avons orient\u00e9 plus&nbsp; +de 1500 patients<\/h5>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c19\" class=\"h-text h-text-component style-4554 style-local-3093-c19 position-relative h-element\">\r\n                  <!---->\r\n                  <!---->\r\n                  <div class=\"\">\r\n                    <p>Une solution pour tous pour une prise en charge pertinente<\/p>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\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-c20-outer\">\r\n            <div data-colibri-id=\"3093-c20\" 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-c20 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c21\" class=\"h-icon style-4552 style-local-3093-c21 position-relative h-element\">\r\n                  <!---->\r\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-c21-icon\"><!--Icon by Font Awesome (https:\/\/fontawesome.com)-->\r\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\">\r\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>\r\n    <\/svg><\/span><\/a>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c22\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c22 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c22\">\r\n                    <!---->\r\n                    <!---->\r\n                    <a href=\"https:\/\/centrepreventiondracenie.fr\/\" h-use-smooth-scroll=\"true\">\r\n                      <h5 class=\"\">des conseils<\/h5>\r\n                    <\/a>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c23\" class=\"h-text h-text-component style-4554 style-local-3093-c23 position-relative h-element\">\r\n                  <!---->\r\n                  <!---->\r\n                  <div class=\"\">\r\n                    <p>T\u00e9l\u00e9phonez ou rendez vous directement au centre de pr\u00e9vention en sant\u00e9&nbsp;<\/p>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\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-c24-outer\">\r\n            <div data-colibri-id=\"3093-c24\" 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-c24 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c25\" class=\"h-icon style-4552 style-local-3093-c25 position-relative h-element\">\r\n                  <!---->\r\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\"\r\n                    h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-4552-icon style-local-3093-c25-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>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c26\" class=\"h-global-transition-all h-heading style-4553 style-local-3093-c26 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-heading__outer style-4553 style-local-3093-c26\">\r\n                    <!---->\r\n                    <!---->\r\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\"\r\n                      h-use-smooth-scroll=\"true\">\r\n                      <h5 class=\"\">Le num\u00e9rique en sant\u00e9<\/h5>\r\n                    <\/a>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c27\" class=\"h-text h-text-component style-4554 style-local-3093-c27 position-relative h-element\">\r\n                  <!---->\r\n                  <!---->\r\n                  <div class=\"\">\r\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>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\n        <\/div>\r\n      <\/div>\r\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-4556 style-local-3093-c28 position-relative\">\r\n        <!---->\r\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\">\r\n          <!---->\r\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-c29-outer\">\r\n            <div data-colibri-id=\"3093-c29\" 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-c29 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c30\" class=\"h-text h-text-component style-4548 style-local-3093-c30 position-relative h-element\">\r\n                  <!---->\r\n                  <!---->\r\n                  <div class=\"\">\r\n                    <h2>Remplissez le formulaire<\/h2>\r\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>\r\n                      <span\r\n                        style=\"font-size: 20px; color: rgb(234, 45, 22); font-weight: 400; font-family: Oswald;\">\r\n                        <br>Pensez \u00e0 regarder vos spams!<\/span>\r\n                        <br><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">1 ADRESSE MAIL PAR DEMANDE<\/span>\r\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>\r\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>\r\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>\r\n                        <br><span style=\"color: rgb(19, 21, 22); font-family: Lato; font-size: 20px; font-weight: 300;\">83300 Draguignan<\/span><\/p>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\n        <\/div>\r\n      <\/div>\r\n    <\/div>\r\n  <\/div>\r\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c31\" 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-c31 position-relative\">\r\n    <!---->\r\n    <!---->\r\n    <div class=\"h-section-grid-container h-section-boxed-container\">\r\n      <!---->\r\n      <div data-colibri-id=\"3093-c32\" 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-c32 position-relative\">\r\n        <!---->\r\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\">\r\n          <!---->\r\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-c33-outer\">\r\n            <div data-colibri-id=\"3093-c33\" 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-c33 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c34\" class=\"style-3803 style-local-3093-c34 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"\">\r\n                    <!-- Begin Brevo Form -->\r\n                    <!-- START - We recommend to place the below code in head tag of your website html  -->\r\n                    <style>\r\n                      @font-face {\r\n                        font-display: block;\r\n                        font-family: Roboto;\r\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\")\r\n                      }\r\n\r\n                      @font-face {\r\n                        font-display: fallback;\r\n                        font-family: Roboto;\r\n                        font-weight: 600;\r\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\")\r\n                      }\r\n\r\n                      @font-face {\r\n                        font-display: fallback;\r\n                        font-family: Roboto;\r\n                        font-weight: 700;\r\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\")\r\n                      }\r\n\r\n                      #sib-container input:-ms-input-placeholder {\r\n                        text-align: left;\r\n                        font-family: Helvetica, sans-serif;\r\n                        color: #c0ccda;\r\n                      }\r\n\r\n                      #sib-container input::placeholder {\r\n                        text-align: left;\r\n                        font-family: Helvetica, sans-serif;\r\n                        color: #c0ccda;\r\n                      }\r\n\r\n                      #sib-container textarea::placeholder {\r\n                        text-align: left;\r\n                        font-family: Helvetica, sans-serif;\r\n                        color: #c0ccda;\r\n                      }\r\n\r\n                      #sib-container a {\r\n                        text-decoration: underline;\r\n                        color: #2BB2FC;\r\n                      }\r\n                    <\/style>\r\n                    <link rel=\"stylesheet\" href=\"https:\/\/sibforms.com\/forms\/end-form\/build\/sib-styles.css\">\r\n                    <!--  END - We recommend to place the above code in head tag of your website html -->\r\n\r\n                    <!-- START - We recommend to place the below code where you want the form in your website html  -->\r\n                    <div class=\"sib-form\" style=\"text-align: center;\r\n         background-color: #EFF2F7;                                 \">\r\n                      <div id=\"sib-form-container\" class=\"sib-form-container\">\r\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;\">\r\n                          <div class=\"sib-form-message-panel__text sib-form-message-panel__text--center\">\r\n                            <svg viewBox=\"0 0 512 512\" class=\"sib-icon sib-notification__icon\">\r\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>\r\n                            <\/svg>\r\n                            <span class=\"sib-form-message-panel__inner-text\">\r\n                          Nous n&rsquo;avons pas pu confirmer votre demande de m\u00e9decin traitant.\r\n                      <\/span>\r\n                          <\/div>\r\n                        <\/div>\r\n                        <div><\/div>\r\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;\">\r\n                          <div class=\"sib-form-message-panel__text sib-form-message-panel__text--center\">\r\n                            <svg viewBox=\"0 0 512 512\" class=\"sib-icon sib-notification__icon\">\r\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>\r\n                            <\/svg>\r\n                            <span class=\"sib-form-message-panel__inner-text\">\r\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\r\n                      <\/span>\r\n                          <\/div>\r\n                        <\/div>\r\n                        <div><\/div>\r\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\">\r\n                          <form id=\"sib-form\" method=\"POST\" action=\"https:\/\/d17c6d89.sibforms.com\/serve\/MUIFAB60tA6AskiFaRPCR8YX79nug2_eb2WdcgChdIcmGn4jR5rQFAXR66NQX9KWffFggUC20E4ox8hg7XS3DD8SZG7G9uUZ0nseYGIRU1DAFcOe0og4jQiFrRjhGRlLHY7fPVeOsmoG-t-fQAL-elP2KwZ7Yg-Gmi0GLooOoAJtemx4t-g5SGyN28Kty06yOJzO4cz19sEoUI_3\"\r\n                            data-type=\"subscription\">\r\n                            <div style=\"padding: 8px 0;\">\r\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\">\r\n                                <p>Demande de m\u00e9decin traitant<\/p>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\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\">\r\n                                <div class=\"sib-text-form-block\">\r\n                                  <p>Votre demande sera trait\u00e9e lors de notre prochaine commission en d\u00e9but de chaque mois.<\/p>\r\n                                  <p>Le pharmacien est habilit\u00e9 \u00e0 renouveler 3 fois votre ordonnance habituelle de traitement.&nbsp;<\/p>\r\n                                  <p>Pour orienter votre demande au mieux, veuillez r\u00e9aliser votre\r\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>\r\n                                  <\/p>\r\n                                  <p>\r\n                                    <br>\r\n                                  <\/p>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\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\">\r\n                                <div class=\"sib-text-form-block\">\r\n                                  <p><strong>En cas d&rsquo;urgence merci de contacter le 15.<\/strong><\/p>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\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\">\r\n                                <div class=\"sib-text-form-block\">\r\n                                  <p>Cartographie du territoire de la CPTS Drac\u00e9nie Provence Verdon<\/p>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-input sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n\r\n                                    <div class=\"entry__field\">\r\n                                      <input class=\"input \" type=\"text\" id=\"EMAIL\" name=\"EMAIL\" autocomplete=\"off\" placeholder=\"EMAIL\" data-required=\"true\" required=\"\">\r\n                                    <\/div>\r\n                                  <\/div>\r\n\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Veuillez renseigner votre adresse email pour vous inscrire. Ex. : abc@xyz.com\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-input sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n\r\n                                    <div class=\"entry__field\">\r\n                                      <input class=\"input \" maxlength=\"200\" type=\"text\" id=\"NOM\" name=\"NOM\" autocomplete=\"off\" placeholder=\"NOM\" data-required=\"true\" required=\"\">\r\n                                    <\/div>\r\n                                  <\/div>\r\n\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-input sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n\r\n                                    <div class=\"entry__field\">\r\n                                      <input class=\"input \" maxlength=\"200\" type=\"text\" id=\"PRENOM\" name=\"PRENOM\" autocomplete=\"off\" placeholder=\"PRENOM\" data-required=\"true\" required=\"\">\r\n                                    <\/div>\r\n                                  <\/div>\r\n\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-sms-field sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n\r\n                                    <div class=\"sib-sms-input-wrapper\" style=\"direction:ltr\">\r\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\">\r\n                                        <div class=\"entry__field\">\r\n                                          <select class=\"input\" name=\"SMS__COUNTRY_CODE\">\r\n                                            <option value=\"+93\">\r\n                                              +93 AF\r\n                                            <\/option>\r\n                                            <option value=\"+358\">\r\n                                              +358 AX\r\n                                            <\/option>\r\n                                            <option value=\"+355\">\r\n                                              +355 AL\r\n                                            <\/option>\r\n                                            <option value=\"+213\">\r\n                                              +213 DZ\r\n                                            <\/option>\r\n                                            <option value=\"+1684\">\r\n                                              +1684 AS\r\n                                            <\/option>\r\n                                            <option value=\"+376\">\r\n                                              +376 AD\r\n                                            <\/option>\r\n                                            <option value=\"+244\">\r\n                                              +244 AO\r\n                                            <\/option>\r\n                                            <option value=\"+1264\">\r\n                                              +1264 AI\r\n                                            <\/option>\r\n                                            <option value=\"+672\">\r\n                                              +672 AQ\r\n                                            <\/option>\r\n                                            <option value=\"+1268\">\r\n                                              +1268 AG\r\n                                            <\/option>\r\n                                            <option value=\"+54\">\r\n                                              +54 AR\r\n                                            <\/option>\r\n                                            <option value=\"+374\">\r\n                                              +374 AM\r\n                                            <\/option>\r\n                                            <option value=\"+297\">\r\n                                              +297 AW\r\n                                            <\/option>\r\n                                            <option value=\"+61\">\r\n                                              +61 AU\r\n                                            <\/option>\r\n                                            <option value=\"+43\">\r\n                                              +43 AT\r\n                                            <\/option>\r\n                                            <option value=\"+994\">\r\n                                              +994 AZ\r\n                                            <\/option>\r\n                                            <option value=\"+1242\">\r\n                                              +1242 BS\r\n                                            <\/option>\r\n                                            <option value=\"+973\">\r\n                                              +973 BH\r\n                                            <\/option>\r\n                                            <option value=\"+880\">\r\n                                              +880 BD\r\n                                            <\/option>\r\n                                            <option value=\"+1246\">\r\n                                              +1246 BB\r\n                                            <\/option>\r\n                                            <option value=\"+375\">\r\n                                              +375 BY\r\n                                            <\/option>\r\n                                            <option value=\"+32\">\r\n                                              +32 BE\r\n                                            <\/option>\r\n                                            <option value=\"+501\">\r\n                                              +501 BZ\r\n                                            <\/option>\r\n                                            <option value=\"+229\">\r\n                                              +229 BJ\r\n                                            <\/option>\r\n                                            <option value=\"+1441\">\r\n                                              +1441 BM\r\n                                            <\/option>\r\n                                            <option value=\"+975\">\r\n                                              +975 BT\r\n                                            <\/option>\r\n                                            <option value=\"+591\">\r\n                                              +591 BO\r\n                                            <\/option>\r\n                                            <option value=\"+599\">\r\n                                              +599 BQ\r\n                                            <\/option>\r\n                                            <option value=\"+387\">\r\n                                              +387 BA\r\n                                            <\/option>\r\n                                            <option value=\"+267\">\r\n                                              +267 BW\r\n                                            <\/option>\r\n                                            <option value=\"+47\">\r\n                                              +47 BV\r\n                                            <\/option>\r\n                                            <option value=\"+55\">\r\n                                              +55 BR\r\n                                            <\/option>\r\n                                            <option value=\"+246\">\r\n                                              +246 IO\r\n                                            <\/option>\r\n                                            <option value=\"+673\">\r\n                                              +673 BN\r\n                                            <\/option>\r\n                                            <option value=\"+359\">\r\n                                              +359 BG\r\n                                            <\/option>\r\n                                            <option value=\"+226\">\r\n                                              +226 BF\r\n                                            <\/option>\r\n                                            <option value=\"+257\">\r\n                                              +257 BI\r\n                                            <\/option>\r\n                                            <option value=\"+855\">\r\n                                              +855 KH\r\n                                            <\/option>\r\n                                            <option value=\"+237\">\r\n                                              +237 CM\r\n                                            <\/option>\r\n                                            <option value=\"+1\">\r\n                                              +1 CA\r\n                                            <\/option>\r\n                                            <option value=\"+34\">\r\n                                              +34 IC\r\n                                            <\/option>\r\n                                            <option value=\"+238\">\r\n                                              +238 CV\r\n                                            <\/option>\r\n                                            <option value=\"+1345\">\r\n                                              +1345 KY\r\n                                            <\/option>\r\n                                            <option value=\"+236\">\r\n                                              +236 CF\r\n                                            <\/option>\r\n                                            <option value=\"+34\">\r\n                                              +34 EA\r\n                                            <\/option>\r\n                                            <option value=\"+235\">\r\n                                              +235 TD\r\n                                            <\/option>\r\n                                            <option value=\"+56\">\r\n                                              +56 CL\r\n                                            <\/option>\r\n                                            <option value=\"+86\">\r\n                                              +86 CN\r\n                                            <\/option>\r\n                                            <option value=\"+61\">\r\n                                              +61 CX\r\n                                            <\/option>\r\n                                            <option value=\"+61\">\r\n                                              +61 CC\r\n                                            <\/option>\r\n                                            <option value=\"+57\">\r\n                                              +57 CO\r\n                                            <\/option>\r\n                                            <option value=\"+269\">\r\n                                              +269 KM\r\n                                            <\/option>\r\n                                            <option value=\"+242\">\r\n                                              +242 CG\r\n                                            <\/option>\r\n                                            <option value=\"+243\">\r\n                                              +243 CD\r\n                                            <\/option>\r\n                                            <option value=\"+682\">\r\n                                              +682 CK\r\n                                            <\/option>\r\n                                            <option value=\"+506\">\r\n                                              +506 CR\r\n                                            <\/option>\r\n                                            <option value=\"+225\">\r\n                                              +225 CI\r\n                                            <\/option>\r\n                                            <option value=\"+385\">\r\n                                              +385 HR\r\n                                            <\/option>\r\n                                            <option value=\"+53\">\r\n                                              +53 CU\r\n                                            <\/option>\r\n                                            <option value=\"+599\">\r\n                                              +599 CW\r\n                                            <\/option>\r\n                                            <option value=\"+357\">\r\n                                              +357 CY\r\n                                            <\/option>\r\n                                            <option value=\"+420\">\r\n                                              +420 CZ\r\n                                            <\/option>\r\n                                            <option value=\"+45\">\r\n                                              +45 DK\r\n                                            <\/option>\r\n                                            <option value=\"+253\">\r\n                                              +253 DJ\r\n                                            <\/option>\r\n                                            <option value=\"+1767\">\r\n                                              +1767 DM\r\n                                            <\/option>\r\n                                            <option value=\"+1809\">\r\n                                              +1809 DO\r\n                                            <\/option>\r\n                                            <option value=\"+1829\">\r\n                                              +1829 DO\r\n                                            <\/option>\r\n                                            <option value=\"+1849\">\r\n                                              +1849 DO\r\n                                            <\/option>\r\n                                            <option value=\"+593\">\r\n                                              +593 EC\r\n                                            <\/option>\r\n                                            <option value=\"+20\">\r\n                                              +20 EG\r\n                                            <\/option>\r\n                                            <option value=\"+503\">\r\n                                              +503 SV\r\n                                            <\/option>\r\n                                            <option value=\"+240\">\r\n                                              +240 GQ\r\n                                            <\/option>\r\n                                            <option value=\"+291\">\r\n                                              +291 ER\r\n                                            <\/option>\r\n                                            <option value=\"+372\">\r\n                                              +372 EE\r\n                                            <\/option>\r\n                                            <option value=\"+251\">\r\n                                              +251 ET\r\n                                            <\/option>\r\n                                            <option value=\"+500\">\r\n                                              +500 FK\r\n                                            <\/option>\r\n                                            <option value=\"+298\">\r\n                                              +298 FO\r\n                                            <\/option>\r\n                                            <option value=\"+679\">\r\n                                              +679 FJ\r\n                                            <\/option>\r\n                                            <option value=\"+358\">\r\n                                              +358 FI\r\n                                            <\/option>\r\n                                            <option value=\"+33\">\r\n                                              +33 FR\r\n                                            <\/option>\r\n                                            <option value=\"+594\">\r\n                                              +594 GF\r\n                                            <\/option>\r\n                                            <option value=\"+689\">\r\n                                              +689 PF\r\n                                            <\/option>\r\n                                            <option value=\"+262\">\r\n                                              +262 TF\r\n                                            <\/option>\r\n                                            <option value=\"+241\">\r\n                                              +241 GA\r\n                                            <\/option>\r\n                                            <option value=\"+220\">\r\n                                              +220 GM\r\n                                            <\/option>\r\n                                            <option value=\"+995\">\r\n                                              +995 GE\r\n                                            <\/option>\r\n                                            <option value=\"+49\">\r\n                                              +49 DE\r\n                                            <\/option>\r\n                                            <option value=\"+233\">\r\n                                              +233 GH\r\n                                            <\/option>\r\n                                            <option value=\"+350\">\r\n                                              +350 GI\r\n                                            <\/option>\r\n                                            <option value=\"+30\">\r\n                                              +30 GR\r\n                                            <\/option>\r\n                                            <option value=\"+299\">\r\n                                              +299 GL\r\n                                            <\/option>\r\n                                            <option value=\"+1473\">\r\n                                              +1473 GD\r\n                                            <\/option>\r\n                                            <option value=\"+590\">\r\n                                              +590 GP\r\n                                            <\/option>\r\n                                            <option value=\"+1671\">\r\n                                              +1671 GU\r\n                                            <\/option>\r\n                                            <option value=\"+502\">\r\n                                              +502 GT\r\n                                            <\/option>\r\n                                            <option value=\"+44\">\r\n                                              +44 GG\r\n                                            <\/option>\r\n                                            <option value=\"+224\">\r\n                                              +224 GN\r\n                                            <\/option>\r\n                                            <option value=\"+245\">\r\n                                              +245 GW\r\n                                            <\/option>\r\n                                            <option value=\"+592\">\r\n                                              +592 GY\r\n                                            <\/option>\r\n                                            <option value=\"+509\">\r\n                                              +509 HT\r\n                                            <\/option>\r\n                                            <option value=\"+672\">\r\n                                              +672 HM\r\n                                            <\/option>\r\n                                            <option value=\"+379\">\r\n                                              +379 VA\r\n                                            <\/option>\r\n                                            <option value=\"+504\">\r\n                                              +504 HN\r\n                                            <\/option>\r\n                                            <option value=\"+852\">\r\n                                              +852 HK\r\n                                            <\/option>\r\n                                            <option value=\"+36\">\r\n                                              +36 HU\r\n                                            <\/option>\r\n                                            <option value=\"+354\">\r\n                                              +354 IS\r\n                                            <\/option>\r\n                                            <option value=\"+91\">\r\n                                              +91 IN\r\n                                            <\/option>\r\n                                            <option value=\"+62\">\r\n                                              +62 ID\r\n                                            <\/option>\r\n                                            <option value=\"+98\">\r\n                                              +98 IR\r\n                                            <\/option>\r\n                                            <option value=\"+964\">\r\n                                              +964 IQ\r\n                                            <\/option>\r\n                                            <option value=\"+353\">\r\n                                              +353 IE\r\n                                            <\/option>\r\n                                            <option value=\"+44\">\r\n                                              +44 IM\r\n                                            <\/option>\r\n                                            <option value=\"+972\">\r\n                                              +972 IL\r\n                                            <\/option>\r\n                                            <option value=\"+39\">\r\n                                              +39 IT\r\n                                            <\/option>\r\n                                            <option value=\"+1876\">\r\n                                              +1876 JM\r\n                                            <\/option>\r\n                                            <option value=\"+81\">\r\n                                              +81 JP\r\n                                            <\/option>\r\n                                            <option value=\"+44\">\r\n                                              +44 JE\r\n                                            <\/option>\r\n                                            <option value=\"+962\">\r\n                                              +962 JO\r\n                                            <\/option>\r\n                                            <option value=\"+7\">\r\n                                              +7 KZ\r\n                                            <\/option>\r\n                                            <option value=\"+254\">\r\n                                              +254 KE\r\n                                            <\/option>\r\n                                            <option value=\"+686\">\r\n                                              +686 KI\r\n                                            <\/option>\r\n                                            <option value=\"+850\">\r\n                                              +850 KP\r\n                                            <\/option>\r\n                                            <option value=\"+82\">\r\n                                              +82 KR\r\n                                            <\/option>\r\n                                            <option value=\"+965\">\r\n                                              +965 KW\r\n                                            <\/option>\r\n                                            <option value=\"+996\">\r\n                                              +996 KG\r\n                                            <\/option>\r\n                                            <option value=\"+856\">\r\n                                              +856 LA\r\n                                            <\/option>\r\n                                            <option value=\"+371\">\r\n                                              +371 LV\r\n                                            <\/option>\r\n                                            <option value=\"+961\">\r\n                                              +961 LB\r\n                                            <\/option>\r\n                                            <option value=\"+266\">\r\n                                              +266 LS\r\n                                            <\/option>\r\n                                            <option value=\"+231\">\r\n                                              +231 LR\r\n                                            <\/option>\r\n                                            <option value=\"+218\">\r\n                                              +218 LY\r\n                                            <\/option>\r\n                                            <option value=\"+423\">\r\n                                              +423 LI\r\n                                            <\/option>\r\n                                            <option value=\"+370\">\r\n                                              +370 LT\r\n                                            <\/option>\r\n                                            <option value=\"+352\">\r\n                                              +352 LU\r\n                                            <\/option>\r\n                                            <option value=\"+853\">\r\n                                              +853 MO\r\n                                            <\/option>\r\n                                            <option value=\"+389\">\r\n                                              +389 MK\r\n                                            <\/option>\r\n                                            <option value=\"+261\">\r\n                                              +261 MG\r\n                                            <\/option>\r\n                                            <option value=\"+265\">\r\n                                              +265 MW\r\n                                            <\/option>\r\n                                            <option value=\"+60\">\r\n                                              +60 MY\r\n                                            <\/option>\r\n                                            <option value=\"+960\">\r\n                                              +960 MV\r\n                                            <\/option>\r\n                                            <option value=\"+223\">\r\n                                              +223 ML\r\n                                            <\/option>\r\n                                            <option value=\"+356\">\r\n                                              +356 MT\r\n                                            <\/option>\r\n                                            <option value=\"+692\">\r\n                                              +692 MH\r\n                                            <\/option>\r\n                                            <option value=\"+596\">\r\n                                              +596 MQ\r\n                                            <\/option>\r\n                                            <option value=\"+222\">\r\n                                              +222 MR\r\n                                            <\/option>\r\n                                            <option value=\"+230\">\r\n                                              +230 MU\r\n                                            <\/option>\r\n                                            <option value=\"+262\">\r\n                                              +262 YT\r\n                                            <\/option>\r\n                                            <option value=\"+52\">\r\n                                              +52 MX\r\n                                            <\/option>\r\n                                            <option value=\"+691\">\r\n                                              +691 FM\r\n                                            <\/option>\r\n                                            <option value=\"+373\">\r\n                                              +373 MD\r\n                                            <\/option>\r\n                                            <option value=\"+377\">\r\n                                              +377 MC\r\n                                            <\/option>\r\n                                            <option value=\"+976\">\r\n                                              +976 MN\r\n                                            <\/option>\r\n                                            <option value=\"+382\">\r\n                                              +382 ME\r\n                                            <\/option>\r\n                                            <option value=\"+1664\">\r\n                                              +1664 MS\r\n                                            <\/option>\r\n                                            <option value=\"+212\">\r\n                                              +212 MA\r\n                                            <\/option>\r\n                                            <option value=\"+258\">\r\n                                              +258 MZ\r\n                                            <\/option>\r\n                                            <option value=\"+95\">\r\n                                              +95 MM\r\n                                            <\/option>\r\n                                            <option value=\"+264\">\r\n                                              +264 NA\r\n                                            <\/option>\r\n                                            <option value=\"+674\">\r\n                                              +674 NR\r\n                                            <\/option>\r\n                                            <option value=\"+977\">\r\n                                              +977 NP\r\n                                            <\/option>\r\n                                            <option value=\"+31\">\r\n                                              +31 NL\r\n                                            <\/option>\r\n                                            <option value=\"+687\">\r\n                                              +687 NC\r\n                                            <\/option>\r\n                                            <option value=\"+64\">\r\n                                              +64 NZ\r\n                                            <\/option>\r\n                                            <option value=\"+505\">\r\n                                              +505 NI\r\n                                            <\/option>\r\n                                            <option value=\"+227\">\r\n                                              +227 NE\r\n                                            <\/option>\r\n                                            <option value=\"+234\">\r\n                                              +234 NG\r\n                                            <\/option>\r\n                                            <option value=\"+683\">\r\n                                              +683 NU\r\n                                            <\/option>\r\n                                            <option value=\"+672\">\r\n                                              +672 NF\r\n                                            <\/option>\r\n                                            <option value=\"+1670\">\r\n                                              +1670 MP\r\n                                            <\/option>\r\n                                            <option value=\"+47\">\r\n                                              +47 NO\r\n                                            <\/option>\r\n                                            <option value=\"+968\">\r\n                                              +968 OM\r\n                                            <\/option>\r\n                                            <option value=\"+92\">\r\n                                              +92 PK\r\n                                            <\/option>\r\n                                            <option value=\"+680\">\r\n                                              +680 PW\r\n                                            <\/option>\r\n                                            <option value=\"+970\">\r\n                                              +970 PS\r\n                                            <\/option>\r\n                                            <option value=\"+507\">\r\n                                              +507 PA\r\n                                            <\/option>\r\n                                            <option value=\"+675\">\r\n                                              +675 PG\r\n                                            <\/option>\r\n                                            <option value=\"+595\">\r\n                                              +595 PY\r\n                                            <\/option>\r\n                                            <option value=\"+51\">\r\n                                              +51 PE\r\n                                            <\/option>\r\n                                            <option value=\"+63\">\r\n                                              +63 PH\r\n                                            <\/option>\r\n                                            <option value=\"+64\">\r\n                                              +64 PN\r\n                                            <\/option>\r\n                                            <option value=\"+48\">\r\n                                              +48 PL\r\n                                            <\/option>\r\n                                            <option value=\"+351\">\r\n                                              +351 PT\r\n                                            <\/option>\r\n                                            <option value=\"+1787\">\r\n                                              +1787 PR\r\n                                            <\/option>\r\n                                            <option value=\"+974\">\r\n                                              +974 QA\r\n                                            <\/option>\r\n                                            <option value=\"+383\">\r\n                                              +383 XK\r\n                                            <\/option>\r\n                                            <option value=\"+262\">\r\n                                              +262 RE\r\n                                            <\/option>\r\n                                            <option value=\"+40\">\r\n                                              +40 RO\r\n                                            <\/option>\r\n                                            <option value=\"+7\">\r\n                                              +7 RU\r\n                                            <\/option>\r\n                                            <option value=\"+250\">\r\n                                              +250 RW\r\n                                            <\/option>\r\n                                            <option value=\"+590\">\r\n                                              +590 BL\r\n                                            <\/option>\r\n                                            <option value=\"+290\">\r\n                                              +290 SH\r\n                                            <\/option>\r\n                                            <option value=\"+1869\">\r\n                                              +1869 KN\r\n                                            <\/option>\r\n                                            <option value=\"+1758\">\r\n                                              +1758 LC\r\n                                            <\/option>\r\n                                            <option value=\"+590\">\r\n                                              +590 MF\r\n                                            <\/option>\r\n                                            <option value=\"+508\">\r\n                                              +508 PM\r\n                                            <\/option>\r\n                                            <option value=\"+1784\">\r\n                                              +1784 VC\r\n                                            <\/option>\r\n                                            <option value=\"+685\">\r\n                                              +685 WS\r\n                                            <\/option>\r\n                                            <option value=\"+378\">\r\n                                              +378 SM\r\n                                            <\/option>\r\n                                            <option value=\"+239\">\r\n                                              +239 ST\r\n                                            <\/option>\r\n                                            <option value=\"+966\">\r\n                                              +966 SA\r\n                                            <\/option>\r\n                                            <option value=\"+221\">\r\n                                              +221 SN\r\n                                            <\/option>\r\n                                            <option value=\"+381\">\r\n                                              +381 RS\r\n                                            <\/option>\r\n                                            <option value=\"+248\">\r\n                                              +248 SC\r\n                                            <\/option>\r\n                                            <option value=\"+232\">\r\n                                              +232 SL\r\n                                            <\/option>\r\n                                            <option value=\"+65\">\r\n                                              +65 SG\r\n                                            <\/option>\r\n                                            <option value=\"+1721\">\r\n                                              +1721 SX\r\n                                            <\/option>\r\n                                            <option value=\"+421\">\r\n                                              +421 SK\r\n                                            <\/option>\r\n                                            <option value=\"+386\">\r\n                                              +386 SI\r\n                                            <\/option>\r\n                                            <option value=\"+677\">\r\n                                              +677 SB\r\n                                            <\/option>\r\n                                            <option value=\"+252\">\r\n                                              +252 SO\r\n                                            <\/option>\r\n                                            <option value=\"+27\">\r\n                                              +27 ZA\r\n                                            <\/option>\r\n                                            <option value=\"+500\">\r\n                                              +500 GS\r\n                                            <\/option>\r\n                                            <option value=\"+211\">\r\n                                              +211 SS\r\n                                            <\/option>\r\n                                            <option value=\"+34\">\r\n                                              +34 ES\r\n                                            <\/option>\r\n                                            <option value=\"+94\">\r\n                                              +94 LK\r\n                                            <\/option>\r\n                                            <option value=\"+249\">\r\n                                              +249 SD\r\n                                            <\/option>\r\n                                            <option value=\"+597\">\r\n                                              +597 SR\r\n                                            <\/option>\r\n                                            <option value=\"+47\">\r\n                                              +47 SJ\r\n                                            <\/option>\r\n                                            <option value=\"+268\">\r\n                                              +268 SZ\r\n                                            <\/option>\r\n                                            <option value=\"+46\">\r\n                                              +46 SE\r\n                                            <\/option>\r\n                                            <option value=\"+41\">\r\n                                              +41 CH\r\n                                            <\/option>\r\n                                            <option value=\"+963\">\r\n                                              +963 SY\r\n                                            <\/option>\r\n                                            <option value=\"+886\">\r\n                                              +886 TW\r\n                                            <\/option>\r\n                                            <option value=\"+992\">\r\n                                              +992 TJ\r\n                                            <\/option>\r\n                                            <option value=\"+255\">\r\n                                              +255 TZ\r\n                                            <\/option>\r\n                                            <option value=\"+66\">\r\n                                              +66 TH\r\n                                            <\/option>\r\n                                            <option value=\"+670\">\r\n                                              +670 TL\r\n                                            <\/option>\r\n                                            <option value=\"+228\">\r\n                                              +228 TG\r\n                                            <\/option>\r\n                                            <option value=\"+690\">\r\n                                              +690 TK\r\n                                            <\/option>\r\n                                            <option value=\"+676\">\r\n                                              +676 TO\r\n                                            <\/option>\r\n                                            <option value=\"+1868\">\r\n                                              +1868 TT\r\n                                            <\/option>\r\n                                            <option value=\"+216\">\r\n                                              +216 TN\r\n                                            <\/option>\r\n                                            <option value=\"+90\">\r\n                                              +90 TR\r\n                                            <\/option>\r\n                                            <option value=\"+993\">\r\n                                              +993 TM\r\n                                            <\/option>\r\n                                            <option value=\"+1649\">\r\n                                              +1649 TC\r\n                                            <\/option>\r\n                                            <option value=\"+688\">\r\n                                              +688 TV\r\n                                            <\/option>\r\n                                            <option value=\"+256\">\r\n                                              +256 UG\r\n                                            <\/option>\r\n                                            <option value=\"+380\">\r\n                                              +380 UA\r\n                                            <\/option>\r\n                                            <option value=\"+971\">\r\n                                              +971 AE\r\n                                            <\/option>\r\n                                            <option value=\"+44\">\r\n                                              +44 GB\r\n                                            <\/option>\r\n                                            <option value=\"+1\">\r\n                                              +1 US\r\n                                            <\/option>\r\n                                            <option value=\"+246\">\r\n                                              +246 UM\r\n                                            <\/option>\r\n                                            <option value=\"+598\">\r\n                                              +598 UY\r\n                                            <\/option>\r\n                                            <option value=\"+998\">\r\n                                              +998 UZ\r\n                                            <\/option>\r\n                                            <option value=\"+678\">\r\n                                              +678 VU\r\n                                            <\/option>\r\n                                            <option value=\"+58\">\r\n                                              +58 VE\r\n                                            <\/option>\r\n                                            <option value=\"+84\">\r\n                                              +84 VN\r\n                                            <\/option>\r\n                                            <option value=\"+1284\">\r\n                                              +1284 VG\r\n                                            <\/option>\r\n                                            <option value=\"+1340\">\r\n                                              +1340 VI\r\n                                            <\/option>\r\n                                            <option value=\"+681\">\r\n                                              +681 WF\r\n                                            <\/option>\r\n                                            <option value=\"+212\">\r\n                                              +212 EH\r\n                                            <\/option>\r\n                                            <option value=\"+967\">\r\n                                              +967 YE\r\n                                            <\/option>\r\n                                            <option value=\"+260\">\r\n                                              +260 ZM\r\n                                            <\/option>\r\n                                            <option value=\"+263\">\r\n                                              +263 ZW\r\n                                            <\/option>\r\n                                          <\/select>\r\n                                        <\/div>\r\n                                        <div class=\"entry__field\" style=\"width: 100%\">\r\n                                          <input type=\"tel\" class=\"input\" id=\"SMS\" name=\"SMS\" autocomplete=\"off\" placeholder=\"SMS\">\r\n                                        <\/div>\r\n                                      <\/div>\r\n                                      <div class=\"sib-sms-tooltip\">\r\n                                        <div class=\"sib-sms-tooltip__box\">\r\n                                          Le champ SMS doit contenir entre 6 et 19 chiffres et inclure le code pays sans utiliser +\/0 (ex. : 33xxxxxxxxx pour la France)\r\n                                        <\/div>\r\n                                        <span class=\"sib-sms-tooltip__icon\">?<\/span>\r\n                                      <\/div>\r\n                                    <\/div>\r\n                                  <\/div>\r\n\r\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;\">\r\n                                  <\/label>\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-input sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n\r\n                                    <div class=\"entry__field\">\r\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\">\r\n                                    <\/div>\r\n                                  <\/div>\r\n\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-input sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n                                    <div class=\"entry__field\">\r\n                                      <input maxlength=\"200\" type=\"text\" data-numeric=\"true\" class=\"input \" id=\"AGE\" name=\"AGE\" autocomplete=\"off\" placeholder=\"AGE\">\r\n                                    <\/div>\r\n                                  <\/div>\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-input sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n\r\n                                    <div class=\"entry__field\">\r\n                                      <input class=\"input \" maxlength=\"200\" type=\"text\" id=\"ADRESSE\" name=\"ADRESSE\" autocomplete=\"off\" placeholder=\"ADRESSE\" data-required=\"true\" required=\"\">\r\n                                    <\/div>\r\n                                  <\/div>\r\n\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Personnalisez ce texte d&rsquo;aide facultatif avant de publier votre formulaire..\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n                                    <div class=\"entry__field\">\r\n                                      <select class=\"input\" id=\"VILLE\" name=\"VILLE\" data-required=\"true\">\r\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\r\n\r\n                                        <option class=\"sib-menu__item\" value=\"1\">\r\n                                          AUPS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"2\">\r\n                                          AIGUINES\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"3\">\r\n                                          DRAGUIGNAN\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"4\">\r\n                                          LES ARCS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"5\">\r\n                                          VIDAUBAN\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"6\">\r\n                                          FLAYOSC\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"7\">\r\n                                          AUTRE\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"8\">\r\n                                          ARTIGNOSC\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"9\">\r\n                                          SALERNES\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"10\">\r\n                                          LORGUES\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"11\">\r\n                                          SAINT ANTONIN\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"12\">\r\n                                          TOURTOUR\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"13\">\r\n                                          VILLECROZE\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"14\">\r\n                                          BAUDUEN\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"15\">\r\n                                          COMPS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"16\">\r\n                                          LA-MOTTE\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"17\">\r\n                                          LE-MUY\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"18\">\r\n                                          LES-ARCS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"19\">\r\n                                          TRANS-EN-PROVENCE\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"20\">\r\n                                          BARGEMON\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"21\">\r\n                                          CALLAS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"22\">\r\n                                          BARGEME\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"23\">\r\n                                          CLAVIER\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"24\">\r\n                                          FIGANIERES\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"25\">\r\n                                          AMPUS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"26\">\r\n                                          MONTFERRAT\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"27\">\r\n                                          REGUSSE\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"28\">\r\n                                          FOX AMPHOUX\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"29\">\r\n                                          LES-SALLES-SUR-VERDON\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"30\">\r\n                                          BAUDINARD\r\n                                        <\/option>\r\n                                      <\/select>\r\n                                    <\/div>\r\n                                  <\/div>\r\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;\">\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-form-block sib-image-form-block\" style=\"text-align: center\">\r\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\">\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n                                    <div class=\"entry__field\">\r\n                                      <select class=\"input\" id=\"DROIT\" name=\"DROIT\" data-required=\"true\">\r\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\r\n\r\n                                        <option class=\"sib-menu__item\" value=\"1\">\r\n                                          ALD\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"2\">\r\n                                          CSS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"3\">\r\n                                          MUTUELLE\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"4\">\r\n                                          PAS DE DROIT\r\n                                        <\/option>\r\n                                      <\/select>\r\n                                    <\/div>\r\n                                  <\/div>\r\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;\">\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n                                    <div class=\"entry__field\">\r\n                                      <select class=\"input\" id=\"MEDTRAITANT\" name=\"MEDTRAITANT\" data-required=\"true\">\r\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\r\n\r\n                                        <option class=\"sib-menu__item\" value=\"1\">\r\n                                          OUI ici\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"2\">\r\n                                          OUI mais dans une autre r\u00e9gion\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"3\">\r\n                                          NON, depuis peu ( moins d&rsquo;un an)\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"4\">\r\n                                          NON, depuis longtemps\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"5\">\r\n                                          NON j&rsquo;en ai jamais eu\r\n                                        <\/option>\r\n                                      <\/select>\r\n                                    <\/div>\r\n                                  <\/div>\r\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;\">\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-select sib-form-block\" data-required=\"true\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n                                    <div class=\"entry__field\">\r\n                                      <select class=\"input\" id=\"DEPLACEMENT\" name=\"DEPLACEMENT\" data-required=\"true\">\r\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\r\n\r\n                                        <option class=\"sib-menu__item\" value=\"1\">\r\n                                          EN CABINET\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"2\">\r\n                                          EN CABINET ACCOMPAGNE(E) OU TAXI\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"3\">\r\n                                          UNIQUEMENT VISITE A DOMICILE\r\n                                        <\/option>\r\n                                      <\/select>\r\n                                    <\/div>\r\n                                  <\/div>\r\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;\">\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-select sib-form-block\">\r\n                                <div class=\"form__entry entry_block\">\r\n                                  <div class=\"form__label-row \">\r\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>\r\n                                    <div class=\"entry__field\">\r\n                                      <select class=\"input\" id=\"PARTENAIRES\" name=\"PARTENAIRES\">\r\n                                        <option value=\"\" disabled=\"\" selected=\"\" hidden=\"\">Choisissez une valeur<\/option>\r\n\r\n                                        <option class=\"sib-menu__item\" value=\"1\">\r\n                                          DAC\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"2\">\r\n                                          CCAS\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"3\">\r\n                                          CHD\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"4\">\r\n                                          PND\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"5\">\r\n                                          AUTRE\r\n                                        <\/option>\r\n                                        <option class=\"sib-menu__item\" value=\"6\">\r\n                                          MISAS\/MAS\r\n                                        <\/option>\r\n                                      <\/select>\r\n                                    <\/div>\r\n                                  <\/div>\r\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;\">\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-optin sib-form-block\">\r\n                                <div class=\"form__entry entry_mcq\">\r\n                                  <div class=\"form__label-row \">\r\n                                    <div class=\"entry__choice\" style=\"\">\r\n                                      <label>\r\n                                        <input type=\"checkbox\" class=\"input_replaced\" value=\"1\" id=\"OPT_IN\" name=\"OPT_IN\">\r\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>\r\n                                    <\/div>\r\n                                  <\/div>\r\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;\">\r\n                                  <\/label>\r\n                                  <label class=\"entry__specification\" style=\"font-size:12px; text-align:left; font-family:Helvetica, sans-serif; color:#8390A4; text-align:left\">\r\n                                    Vous pouvez vous d\u00e9sinscrire \u00e0 tout moment en cliquant sur le lien pr\u00e9sent dans nos emails.\r\n                                  <\/label>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-form__declaration\" style=\"direction:ltr\">\r\n                                <div class=\"declaration-block-icon\">\r\n                                  <svg class=\"icon__SVG\" width=\"0\" height=\"0\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\">\r\n                                    <defs>\r\n                                      <symbol id=\"svgIcon-sphere\" viewBox=\"0 0 63 63\">\r\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\"\r\n                                         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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\r\n                                    <a target=\"_blank\"\r\n                                      href=\"https:\/\/www.brevo.com\/fr\/legal\/privacypolicy\/\">\u00e0 la politique de confidentialit\u00e9 de Brevo.<\/a>\r\n                                  <\/p>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                            <div style=\"padding: 8px 0;\">\r\n                              <div class=\"sib-form-block\" style=\"text-align: left\">\r\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\"\r\n                                  type=\"submit\">\r\n                                  <svg class=\"icon clickable__icon progress-indicator__icon sib-hide-loader-icon\" viewBox=\"0 0 512 512\" style=\"\">\r\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>\r\n                                  <\/svg>\r\n                                  VALIDER\r\n                                <\/button>\r\n                              <\/div>\r\n                            <\/div>\r\n\r\n                            <input type=\"text\" name=\"email_address_check\" value=\"\" class=\"input--hidden\">\r\n                            <input type=\"hidden\" name=\"locale\" value=\"fr\">\r\n                          <\/form>\r\n                        <\/div>\r\n                      <\/div>\r\n                    <\/div>\r\n                    <!-- END - We recommend to place the above code where you want the form in your website html  -->\r\n\r\n                    <!-- START - We recommend to place the below code in footer or bottom of your website html  -->\r\n                    <script>\r\n                      window.REQUIRED_CODE_ERROR_MESSAGE = 'Veuillez choisir un code pays';\r\n                      window.LOCALE = 'fr';\r\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.\";\r\n\r\n                      window.REQUIRED_ERROR_MESSAGE = \"Vous devez renseigner ce champ. \";\r\n\r\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.\";\r\n\r\n                      window.INVALID_NUMBER = \"Les informations que vous avez fournies ne sont pas valides. Veuillez v\u00e9rifier le format du champ et r\u00e9essayer.\";\r\n\r\n\r\n\r\n                      window.translation = {\r\n                        common: {\r\n                          selectedList: '{quantity} liste s\u00e9lectionn\u00e9e',\r\n                          selectedLists: '{quantity} listes s\u00e9lectionn\u00e9es',\r\n                          selectedOption: '{quantity} s\u00e9lectionn\u00e9',\r\n                          selectedOptions: '{quantity} s\u00e9lectionn\u00e9s',\r\n                        }\r\n                      };\r\n\r\n                      var AUTOHIDE = Boolean(0);\r\n                    <\/script>\r\n\r\n                    <script defer=\"\" src=\"https:\/\/sibforms.com\/forms\/end-form\/build\/main.js\"><\/script>\r\n\r\n\r\n                    <!-- END - We recommend to place the above code in footer or bottom of your website html  -->\r\n                    <!-- End Brevo Form -->\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\n        <\/div>\r\n      <\/div>\r\n    <\/div>\r\n  <\/div>\r\n  <div data-colibri-component=\"section\" data-colibri-id=\"3093-c35\" 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-c35 position-relative\">\r\n    <!---->\r\n    <!---->\r\n    <div class=\"h-section-grid-container h-section-boxed-container\">\r\n      <!---->\r\n      <div data-colibri-id=\"3093-c36\" 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-c36 position-relative\">\r\n        <!---->\r\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\">\r\n          <!---->\r\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-c37-outer\">\r\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-3495 style-local-3093-c37 position-relative\">\r\n              <div class=\"background-wrapper\">\r\n                <div class=\"background-layer background-layer-media-container-lg\">\r\n                  <!---->\r\n                  <div class=\"overlay-layer\">\r\n                    <div class=\"overlay-image-layer\" style=\"background-color: rgb(226, 235, 231); opacity: 0.8;\"><\/div>\r\n                  <\/div>\r\n                <\/div>\r\n                <div class=\"background-layer background-layer-media-container-md\">\r\n                  <!---->\r\n                  <div class=\"overlay-layer\">\r\n                    <div class=\"overlay-image-layer\" style=\"background-color: rgb(226, 235, 231); opacity: 0.8;\"><\/div>\r\n                  <\/div>\r\n                <\/div>\r\n                <div class=\"background-layer background-layer-media-container\">\r\n                  <!---->\r\n                  <div class=\"overlay-layer\">\r\n                    <div class=\"overlay-image-layer\" style=\"background-color: rgb(226, 235, 231); opacity: 0.8;\"><\/div>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c38\" class=\"h-global-transition-all h-heading style-3496 style-local-3093-c38 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-heading__outer style-3496 style-local-3093-c38\">\r\n                    <!---->\r\n                    <!---->\r\n                    <h3 class=\"\"><span style=\"font-weight: 400;\">R\u00e9alisez votre bilan de pr\u00e9vention pour fluidifier votre orientation<\/span><\/h3>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c39\" class=\"h-text h-text-component style-3497 style-local-3093-c39 position-relative h-element\">\r\n                  <!---->\r\n                  <!---->\r\n                  <div class=\"\">\r\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>\r\n                  <\/div>\r\n                <\/div>\r\n                <div data-colibri-id=\"3093-c40\" class=\"h-x-container style-3498 style-local-3093-c40 position-relative h-element\">\r\n                  <!---->\r\n                  <div class=\"h-x-container-inner style-dynamic-3093-c40-group style-3498-spacing style-local-3093-c40-spacing\"><span class=\"h-button__outer style-3499-outer style-local-3093-c41-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-c41\" 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-c41 position-relative\"><!----><!----> <span>RDV bilan de pr\u00e9vention -GRATUIT-<\/span><\/a>\r\n                    <\/span><span class=\"h-button__outer style-3518-outer style-local-3093-c42-outer d-inline-flex h-element\"><a h-use-smooth-scroll=\"true\" href=\"https:\/\/centrepreventiondracenie.fr\/\"  data-colibri-id=\"3093-c42\" 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-c42 position-relative\"><!----><!----> <span>Plus d&rsquo;informations<\/span><\/a>\r\n                    <\/span>\r\n                  <\/div>\r\n                <\/div>\r\n              <\/div>\r\n            <\/div>\r\n          <\/div>\r\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-c43-outer\">\r\n            <div data-colibri-id=\"3093-c43\" 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-c43 position-relative\">\r\n              <!---->\r\n              <!---->\r\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\">\r\n                <!---->\r\n                <div data-colibri-id=\"3093-c44\" 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-c44 position-relative\">\r\n                  <!---->\r\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\">\r\n                    <!---->\r\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-c45-outer\">\r\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-3502 style-local-3093-c45 position-relative\">\r\n                        <div class=\"background-wrapper\">\r\n                          <div class=\"background-layer background-layer-media-container-lg\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container-md\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                        <\/div>\r\n                        <!---->\r\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\">\r\n                          <!---->\r\n                          <div data-colibri-id=\"3093-c46\" class=\"h-global-transition-all h-heading style-3505 style-local-3093-c46 position-relative h-element\">\r\n                            <!---->\r\n                            <div class=\"h-heading__outer style-3505 style-local-3093-c46\">\r\n                              <!---->\r\n                              <!---->\r\n                              <h5 class=\"\">18-25 ans<\/h5>\r\n                            <\/div>\r\n                          <\/div>\r\n                        <\/div>\r\n                      <\/div>\r\n                    <\/div>\r\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-c47-outer\">\r\n                      <div data-colibri-id=\"3093-c47\" 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-c47 position-relative\">\r\n                        <div class=\"background-wrapper\">\r\n                          <div class=\"background-layer background-layer-media-container-lg\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container-md\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                        <\/div>\r\n                        <!---->\r\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\">\r\n                          <!---->\r\n                          <div data-colibri-component=\"content-swap\" data-colibri-id=\"3093-c48\" class=\"content-swap style-3509 style-local-3093-c48 position-relative h-element\">\r\n                            <!---->\r\n                            <div class=\"d-flex position-relative border-radius-inherit h-content-swap__overflow\">\r\n                              <div data-normal=\"\" data-colibri-id=\"3093-c49\" class=\"h-content-swap__normal d-flex border-radius-inherit hide-animation style-3504 style-local-3093-c49 position-relative\">\r\n                                <!---->\r\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\r\n                                  <!---->\r\n                                  <div data-colibri-id=\"3093-c50\" class=\"h-global-transition-all h-heading style-3505 style-local-3093-c50 position-relative h-element\">\r\n                                    <!---->\r\n                                    <div class=\"h-heading__outer style-3505 style-local-3093-c50\">\r\n                                      <!---->\r\n                                      <!---->\r\n                                      <h5 class=\"\">45-50 ans<\/h5>\r\n                                    <\/div>\r\n                                  <\/div>\r\n                                <\/div>\r\n                              <\/div>\r\n                              <div data-hover=\"\" data-colibri-component=\"link\" data-href=\"\" data-colibri-id=\"3093-c51\" 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-c51 position-relative\"\r\n                                style=\"display: none;\">\r\n                                <!---->\r\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\r\n                                  <!---->\r\n                                  <div data-colibri-id=\"3093-c52\" class=\"h-icon style-3507 style-local-3093-c52 position-relative h-element\">\r\n                                    <!---->\r\n                                    <a href=\"#\" h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-3507-icon style-local-3093-c52-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>\r\n                                  <\/div>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                        <\/div>\r\n                      <\/div>\r\n                    <\/div>\r\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-c53-outer\">\r\n                      <div data-colibri-id=\"3093-c53\" 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-c53 position-relative\">\r\n                        <div class=\"background-wrapper\">\r\n                          <div class=\"background-layer background-layer-media-container-lg\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container-md\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                        <\/div>\r\n                        <!---->\r\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\">\r\n                          <!---->\r\n                          <div data-colibri-component=\"content-swap\" data-colibri-id=\"3093-c54\" class=\"content-swap style-3511 style-local-3093-c54 position-relative h-element\">\r\n                            <!---->\r\n                            <div class=\"d-flex position-relative border-radius-inherit h-content-swap__overflow\">\r\n                              <div data-normal=\"\" data-colibri-id=\"3093-c55\" class=\"h-content-swap__normal d-flex border-radius-inherit hide-animation style-3504 style-local-3093-c55 position-relative\">\r\n                                <!---->\r\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\r\n                                  <!---->\r\n                                  <div data-colibri-id=\"3093-c56\" class=\"h-global-transition-all h-heading style-3505 style-local-3093-c56 position-relative h-element\">\r\n                                    <!---->\r\n                                    <div class=\"h-heading__outer style-3505 style-local-3093-c56\">\r\n                                      <!---->\r\n                                      <!---->\r\n                                      <h5 class=\"\">60-65 ans<\/h5>\r\n                                    <\/div>\r\n                                  <\/div>\r\n                                <\/div>\r\n                              <\/div>\r\n                              <div data-hover=\"\" data-colibri-component=\"link\" data-href=\"\" data-colibri-id=\"3093-c57\" 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-c57 position-relative\"\r\n                                style=\"display: none;\">\r\n                                <!---->\r\n                                <div class=\"w-100 h-y-container align-self-lg-center align-self-md-center align-self-center\">\r\n                                  <!---->\r\n                                  <div data-colibri-id=\"3093-c58\" class=\"h-icon style-3507 style-local-3093-c58 position-relative h-element\">\r\n                                    <!---->\r\n                                    <a href=\"#\" h-use-smooth-scroll=\"true\"><span class=\"h-svg-icon h-icon__icon style-3507-icon style-local-3093-c58-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>\r\n                                  <\/div>\r\n                                <\/div>\r\n                              <\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                        <\/div>\r\n                      <\/div>\r\n                    <\/div>\r\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-c59-outer\">\r\n                      <div data-colibri-id=\"3093-c59\" 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-c59 position-relative\">\r\n                        <div class=\"background-wrapper\">\r\n                          <div class=\"background-layer background-layer-media-container-lg\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container-md\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                          <div class=\"background-layer background-layer-media-container\">\r\n                            <!---->\r\n                            <div class=\"overlay-layer\">\r\n                              <div class=\"overlay-image-layer\" style=\"background-color: rgb(3, 12, 73); opacity: 0.7;\"><\/div>\r\n                            <\/div>\r\n                          <\/div>\r\n                        <\/div>\r\n                        <!---->\r\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\">\r\n                          <!---->\r\n                          <div data-colibri-component=\"content-swap\" data-colibri-id=\"3093-c60\" class=\"content-swap style-3513 style-local-3093-c60 position-relative h-element\">\r\n                            <!---->\r\n                            <div class=\"d-flex position-relative border-radius-inherit h-content-swap__overflow\">\r\n                              <div data-normal=\"\" 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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":3104,"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","has-post-thumbnail","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.7 - 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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