Je recherche un médecin traitant

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Accepted Answer

<p>
<div class="wpcf7 no-js" id="wpcf7-f162-p95-o2" lang="fr-FR" dir="ltr" data-wpcf7-id="162">
<div class="screen-reader-response"><p role="status" aria-live="polite" aria-atomic="true"></p> <ul></ul></div>
<form action="/contact/#wpcf7-f162-p95-o2" method="post" class="wpcf7-form init" aria-label="Formulaire de contact" novalidate="novalidate" data-status="init">
<div style="display: none;">
<input type="hidden" name="_wpcf7" value="162" />
<input type="hidden" name="_wpcf7_version" value="6.0" />
<input type="hidden" name="_wpcf7_locale" value="fr_FR" />
<input type="hidden" name="_wpcf7_unit_tag" value="wpcf7-f162-p95-o2" />
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<input type="hidden" name="_wpcf7cf_steps" value="{}" />
<input type="hidden" name="_wpcf7cf_options" value="{"form_id":162,"conditions":[{"then_field":"groupe-medecin","and_rules":[{"if_field":"raison","operator":"equals","if_value":"d\u00e9part de mon m\u00e9decin traitant"}]}],"settings":{"animation":"yes","animation_intime":200,"animation_outtime":200,"conditions_ui":"normal","notice_dismissed":false,"notice_dismissed_rollback-cf7-5.6":true,"notice_dismissed_rollback-cf7-5.6.4":true,"notice_dismissed_rollback-cf7-5.8.3":true,"notice_dismissed_rollback-cf7-5.8.7":true,"notice_dismissed_rollback-cf7-5.9.2":true}}" />
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</div>
<div class="oceanwp-row clr">
	<div class="span_1_of_2 col col-1">
		<p><label>Mon prénom <em>(obligatoire)</em><br />
<span class="wpcf7-form-control-wrap" data-name="prenom"><input size="40" maxlength="400" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="prenom" /></span> </label>
		</p>
	</div>
	<div class="span_1_of_2 col">
		<p><label>Mon nom <em>(obligatoire)</em><br />
<span class="wpcf7-form-control-wrap" data-name="nom"><input size="40" maxlength="400" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="nom" /></span> </label>
		</p>
	</div>
</div>
<div class="oceanwp-row clr">
	<div class="span_1_of_1 col">
		<p><label>Mon lieu de résidence <em>(obligatoire)</em><br />
<span class="wpcf7-form-control-wrap" data-name="residence"><input size="40" maxlength="400" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="residence" /></span> </label>
		</p>
	</div>
</div>
<div class="oceanwp-row clr">
	<div class="span_1_of_2 col col-1">
		<p><label>Mon adresse e-mail <em>(obligatoire)</em><br />
<span class="wpcf7-form-control-wrap" data-name="email"><input size="40" maxlength="400" class="wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email" aria-required="true" aria-invalid="false" value="" type="email" name="email" /></span></label>
		</p>
	</div>
	<div class="span_1_of_2 col"
<label>
		<p>Mon n° de téléphone<br />
<span class="wpcf7-form-control-wrap" data-name="telephone"><input size="40" maxlength="400" class="wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel" aria-invalid="false" value="" type="tel" name="telephone" /></span>
		</p>
	</div>
</div>
<div class="oceanwp-row clr">
	<div class="span_1_of_2 col col-1">
		<p><label>Personnes de mon foyer concernées par cette demande <em>(obligatoire)</em><br />
<span class="wpcf7-form-control-wrap" data-name="foyer"><input class="wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number" min="1" aria-required="true" aria-invalid="false" value="1" type="number" name="foyer" /></span></label>
		</p>
	</div>
	<div class="span_1_of_2 col">
		<p><label>Raison de ma demande <em>(obligatoire)</em><br />
<span class="wpcf7-form-control-wrap" data-name="raison"><select class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required" aria-required="true" aria-invalid="false" name="raison"><option value="">&#8212;Veuillez choisir une option&#8212;</option><option value="nouvel arrivant sur le territoire">nouvel arrivant sur le territoire</option><option value="départ de mon médecin traitant">départ de mon médecin traitant</option></select></span></label>
		</p>
	</div>
</div>
<div data-id="groupe-medecin" data-orig_data_id="groupe-medecin" data-clear_on_hide data-class="wpcf7cf_group">
	<div class="oceanwp-row clr">
		<div class="span_1_of_2 col col-1">
			<p><label>Prénom et nom de mon précédent médecin traitant <em>(obligatoire)</em><br />
<span class="wpcf7-form-control-wrap" data-name="medecin"><input size="40" maxlength="400" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false" value="" type="text" name="medecin" /></span></label>
			</p>
		</div>
	</div>
</div>
<div class="oceanwp-row clr">
	<div class="span_1_of_1 col">
		<p><input class="wpcf7-form-control wpcf7-submit has-spinner" type="submit" value="J'envoie ma demande" />
		</p>
		<p><strong>Vos données ne sont collectées que par et pour la CPTS Pays de Gex. Elles ne font en aucun cas l&rsquo;objet d&rsquo;un transfert à un tiers. Elles serviront afin de pouvoir vous recontacter et donner suite à votre demande.</strong>
		</p>
	</div>
</div><p style="display: none !important;" class="akismet-fields-container" data-prefix="_wpcf7_ak_"><label>&#916;<textarea name="_wpcf7_ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_2" name="_wpcf7_ak_js" value="136"/><script>document.getElementById( "ak_js_2" ).setAttribute( "value", ( new Date() ).getTime() );</script></p><div class="wpcf7-response-output" aria-hidden="true"></div>
</form>
</div>
</p>

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Je recherche un médecin traitant

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