Je recherche un médecin traitant

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Accepted Answer

<p>
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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>
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	<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>
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<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>
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</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>
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<label>
		<p>Mon n° de téléphone<br />
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		</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 />
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		</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>
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	<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>
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	</div>
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		</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>
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</p>

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Je recherche un médecin traitant

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