{"id":2664,"date":"2025-03-06T11:43:20","date_gmt":"2025-03-06T10:43:20","guid":{"rendered":"https:\/\/www.physidia.com\/?page_id=2664"},"modified":"2026-04-27T10:22:26","modified_gmt":"2026-04-27T08:22:26","slug":"inscription-patient","status":"publish","type":"page","link":"https:\/\/nehomy.com\/en\/inscription-patient\/","title":{"rendered":"Patient Subscription"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2664\" class=\"elementor elementor-2664\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bdc657c e-con-full e-flex e-con e-parent\" data-id=\"bdc657c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-aa43612 e-flex e-con-boxed e-con e-child\" data-id=\"aa43612\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-2600ab6 e-con-full e-flex e-con e-child\" data-id=\"2600ab6\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4196be6 form-white elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"4196be6\" data-element_type=\"widget\" data-e-type=\"widget\" id=\"formulaire-patient\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<link rel='stylesheet' id='dashicons-css' href='https:\/\/nehomy.com\/wp-includes\/css\/dashicons.min.css?ver=6.9.4' media='all' \/>\n<script src=\"https:\/\/nehomy.com\/wp-includes\/js\/dist\/dom-ready.min.js?ver=f77871ff7694fffea381\" id=\"wp-dom-ready-js\"><\/script>\n<script src=\"https:\/\/nehomy.com\/wp-includes\/js\/dist\/hooks.min.js?ver=dd5603f07f9220ed27f1\" id=\"wp-hooks-js\"><\/script>\n<script src=\"https:\/\/nehomy.com\/wp-includes\/js\/dist\/i18n.min.js?ver=c26c3dc7bed366793375\" id=\"wp-i18n-js\"><\/script>\n<script id=\"wp-i18n-js-after\">\nwp.i18n.setLocaleData( { 'text direction\\u0004ltr': [ 'ltr' ] } );\n\/\/# sourceURL=wp-i18n-js-after\n<\/script>\n<script id=\"wp-a11y-js-translations\">\n( function( domain, translations ) {\n\tvar localeData = translations.locale_data[ domain ] || translations.locale_data.messages;\n\tlocaleData[\"\"].domain = domain;\n\twp.i18n.setLocaleData( localeData, domain );\n} )( \"default\", {\"translation-revision-date\":\"2026-04-17 10:35:12+0000\",\"generator\":\"GlotPress\\\/4.0.3\",\"domain\":\"messages\",\"locale_data\":{\"messages\":{\"\":{\"domain\":\"messages\",\"plural-forms\":\"nplurals=2; plural=n != 1;\",\"lang\":\"en_GB\"},\"Notifications\":[\"Notifications\"]}},\"comment\":{\"reference\":\"wp-includes\\\/js\\\/dist\\\/a11y.js\"}} );\n\/\/# sourceURL=wp-a11y-js-translations\n<\/script>\n<script src=\"https:\/\/nehomy.com\/wp-includes\/js\/dist\/a11y.min.js?ver=cb460b4676c94bd228ed\" id=\"wp-a11y-js\"><\/script>\n<script src=\"https:\/\/nehomy.com\/wp-includes\/js\/jquery\/jquery.min.js?ver=3.7.1\" id=\"jquery-core-js\"><\/script>\n<script defer='defer' src=\"https:\/\/nehomy.com\/wp-content\/plugins\/gravityforms\/js\/jquery.json.min.js?ver=2.10.1\" id=\"gform_json-js\"><\/script>\n<script id=\"gform_gravityforms-js-extra\">\nvar gf_field_checkbox = {\"strings\":{\"selected\":\"All choices are selected.\",\"deselected\":\"All choices are unselected.\"}};\nvar gf_global = {\"gf_currency_config\":{\"name\":\"Euro\",\"symbol_left\":\"\",\"symbol_right\":\"&#8364;\",\"symbol_padding\":\" \",\"thousand_separator\":\".\",\"decimal_separator\":\",\",\"decimals\":2,\"code\":\"EUR\"},\"base_url\":\"https:\/\/nehomy.com\/wp-content\/plugins\/gravityforms\",\"number_formats\":[],\"spinnerUrl\":\"https:\/\/nehomy.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg\",\"version_hash\":\"89ef089ec4a68ed96fc99466ad88bda6\",\"strings\":{\"newRowAdded\":\"New row added.\",\"rowRemoved\":\"Row removed\",\"formSaved\":\"The form has been saved.  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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_12' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/en\/wp-json\/wp\/v2\/pages\/2664#gf_12' data-formid='12' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeaKrosAAAAABsZkKYvqiuEECHAYLAmPv_XPmBr' data-tabindex='0'><input id=\"input_fd8682e092e7bea48f7e2332284c56a1\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_fd8682e092e7bea48f7e2332284c56a1\" value=\"\"\/><\/div>\n        <div id='gf_progressbar_wrapper_12' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>13<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_7' style='width:7%; color:#fff; background-color:#fff;'><span>7%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_12_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_80\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_80'>Comments<\/label><div class='gfield_description' id='gfield_description_12_80'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_80' id='input_12_80' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_12_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h1>Souhaitez-vous vous inscrire <strong>\u00e0 votre espace priv\u00e9\u00a0?<\/strong><\/h1><\/div><div id=\"field_12_31\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Pour le cr\u00e9er, c\u2019est simple, gratuit et ne prendra que quelques minutes.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_12_18' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_2' class='gform_page' data-js='page-field-id-18' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_22\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Bienvenue !<\/h3>\n<\/div><div id=\"field_12_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_36'>Quel est votre pr\u00e9nom\u00a0?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_12_36' type='text' value='' class='large'    placeholder='Pr\u00e9nom' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_34'>Et, votre nom\u00a0\u00a0?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_12_34' type='text' value='' class='large'    placeholder='Nom' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_35' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_35' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_3' class='gform_page' data-js='page-field-id-35' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_37\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Merci . Vous pouvez maintenant d\u00e9finir votre acc\u00e8s personnel\u00a0:<\/h3>\n<\/div><div id=\"field_12_78\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_78'>Quel est votre adresse email\u00a0?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_78' id='input_12_78' type='email' value='' class='large'   placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_12_4\" class=\"gfield gfield--type-password gfield--input-type-password gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >D\u00e9finissez le mot de passe de votre compte *<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_password gform-grid-row' id='input_12_4_container'>\n\t\t\t\t\t\t<span id='input_12_4_1_container' class='ginput_password ginput_left gform-grid-col gform-grid-col--size-auto'>\n\t\t\t\t\t\t\t<label for='input_12_4' class='gform-field-label gform-field-label--type-sub '>Enter Password<\/label>\n\t\t\t\t\t\t\t<span class='password_input_container'>\n\t\t\t\t\t\t\t<input type='password' name='input_4' id='input_12_4' onkeyup='gformShowPasswordStrength(\"input_12_4\");' onchange='gformShowPasswordStrength(\"input_12_4\");' aria-describedby=\"input_12_4_strength_indicator\" value=''  placeholder='Mot de passe' aria-required=\"true\" aria-invalid=\"false\" \/>\n\t\t\t\t\t\t\t<button type='button' class='gform_show_password gform-theme-button gform-theme-button--simple' onclick='javascript:gformToggleShowPassword(\"input_12_4\");' aria-live='polite' aria-label='Show Password' data-label-show='Show Password' data-label-hide='Hide Password'><span class='dashicons dashicons-hidden' aria-hidden='true'><\/span><\/button>\n\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<span id='input_12_4_2_container' class='ginput_password ginput_right gform-grid-col gform-grid-col--size-auto'>\n\t\t\t\t\t\t\t<label for='input_12_4_2' class='gform-field-label gform-field-label--type-sub '>Confirm Password<\/label>\n\t\t\t\t\t\t\t<span class='password_input_container'>\n\t\t\t\t\t\t\t<input type='password' name='input_4_2' id='input_12_4_2' onkeyup='gformShowPasswordStrength(\"input_12_4\");' onchange='gformShowPasswordStrength(\"input_12_4\");' value=''  placeholder='Mot de passe' aria-required=\"true\" aria-invalid=\"false\" \/>\n\t\t\t\t\t\t\t<button type='button' class='gform_show_password gform-theme-button gform-theme-button--simple' onclick='javascript:gformToggleShowPassword(\"input_12_4_2\");' aria-live='polite' aria-label='Show Password' data-label-show='Show Password' data-label-hide='Hide Password'><span class='dashicons dashicons-hidden' aria-hidden='true'><\/span><\/button>\n\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<div class='gf_clear gf_clear_complex'><\/div>\n\t\t\t\t\t<\/div><div id='input_12_4_strength_indicator' class='gfield_password_strength'  aria-live='assertive' aria-atomic='true'>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tStrength indicator\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input type='hidden' class='gform_hidden' id='input_12_4_strength' name='input_4_strength' \/><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_39' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_39' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_4' class='gform_page' data-js='page-field-id-39' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_4' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>, \u00eates-vous un\u00a0: <\/h3>\n<\/div><fieldset id=\"field_12_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Vous \u00eates<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_24'>\n\t\t\t<div class='gchoice gchoice_12_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='patient'  id='choice_12_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_24_0' id='label_12_24_0' class='gform-field-label gform-field-label--type-inline'>Patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='proche-aidant'  id='choice_12_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_24_1' id='label_12_24_1' class='gform-field-label gform-field-label--type-inline'>Proche aidant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_24_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='famille'  id='choice_12_24_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_24_2' id='label_12_24_2' class='gform-field-label gform-field-label--type-inline'>Membre de la famille\/proche d\u2019un patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_24_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='autre'  id='choice_12_24_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_24_3' id='label_12_24_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_75'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_12_75' type='text' value='' class='large'    placeholder='Autre'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_41' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_41' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_5' class='gform_page' data-js='page-field-id-41' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_12_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00c0 quel stade est votre insuffisance r\u00e9nale ou celle de votre proche\u00a0?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_42'>\n\t\t\t<div class='gchoice gchoice_12_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Stade 1 :\u00a0L\u00e9sion r\u00e9nale avec une fonction r\u00e9nale normale (Filtration Glom\u00e9rulaire &gt; 90 mL\/min). Peu ou pas de sympt\u00f4mes.'  id='choice_12_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_0' id='label_12_42_0' class='gform-field-label gform-field-label--type-inline'>Stade 1 :\u00a0L\u00e9sion r\u00e9nale avec une fonction r\u00e9nale normale (Filtration Glom\u00e9rulaire &gt; 90 mL\/min). Peu ou pas de sympt\u00f4mes.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Stade 2 :\u00a0D\u00e9but d\u2019une insuffisance r\u00e9nale l\u00e9g\u00e8re (Filtration entre 60 et 89 mL\/min). Une surveillance m\u00e9dicale est recommand\u00e9e.'  id='choice_12_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_1' id='label_12_42_1' class='gform-field-label gform-field-label--type-inline'>Stade 2 :\u00a0D\u00e9but d\u2019une insuffisance r\u00e9nale l\u00e9g\u00e8re (Filtration entre 60 et 89 mL\/min). Une surveillance m\u00e9dicale est recommand\u00e9e.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Stade 3 :\u00a0Insuffisance r\u00e9nale mod\u00e9r\u00e9e (Filtration entre 30 et 59 mL\/min). Les premiers sympt\u00f4mes peuvent appara\u00eetre.'  id='choice_12_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_2' id='label_12_42_2' class='gform-field-label gform-field-label--type-inline'>Stade 3 :\u00a0Insuffisance r\u00e9nale mod\u00e9r\u00e9e (Filtration entre 30 et 59 mL\/min). Les premiers sympt\u00f4mes peuvent appara\u00eetre.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Stade 4 :\u00a0Insuffisance r\u00e9nale s\u00e9v\u00e8re (Filtration entre 15 et 29 mL\/min). La pr\u00e9paration \u00e0 un traitement de suppl\u00e9ance (dialyse ou greffe) doit \u00eatre envisag\u00e9e.'  id='choice_12_42_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_3' id='label_12_42_3' class='gform-field-label gform-field-label--type-inline'>Stade 4 :\u00a0Insuffisance r\u00e9nale s\u00e9v\u00e8re (Filtration entre 15 et 29 mL\/min). La pr\u00e9paration \u00e0 un traitement de suppl\u00e9ance (dialyse ou greffe) doit \u00eatre envisag\u00e9e.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='Stade 5 :\u00a0 Insuffisance r\u00e9nale terminale (Filtration &lt; 15 mL\/min). Une prise en charge par dialyse ou une greffe r\u00e9nale devient indispensable.'  id='choice_12_42_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_4' id='label_12_42_4' class='gform-field-label gform-field-label--type-inline'>Stade 5 :\u00a0 Insuffisance r\u00e9nale terminale (Filtration &lt; 15 mL\/min). Une prise en charge par dialyse ou une greffe r\u00e9nale devient indispensable.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou votre proche a-t-il un traitement de suppl\u00e9ance ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_43'>\n\t\t\t<div class='gchoice gchoice_12_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Pas encore au stade de la suppl\u00e9ance'  id='choice_12_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_0' id='label_12_43_0' class='gform-field-label gform-field-label--type-inline'>Pas encore au stade de la suppl\u00e9ance<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Traitement conservateur'  id='choice_12_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_1' id='label_12_43_1' class='gform-field-label gform-field-label--type-inline'>Traitement conservateur<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Greffe r\u00e9nale'  id='choice_12_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_2' id='label_12_43_2' class='gform-field-label gform-field-label--type-inline'>Greffe r\u00e9nale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Dialyse en centre'  id='choice_12_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_3' id='label_12_43_3' class='gform-field-label gform-field-label--type-inline'>Dialyse en centre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Dialyse \u00e0 domicile'  id='choice_12_43_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_4' id='label_12_43_4' class='gform-field-label gform-field-label--type-inline'>Dialyse \u00e0 domicile<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Autre'  id='choice_12_43_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_5' id='label_12_43_5' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_76'>Autre traitement<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_12_76' type='text' value='' class='large'    placeholder='Autre'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_73' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_73' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_6' class='gform_page' data-js='page-field-id-73' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_6' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_46'>Etablissement o\u00f9 a \u00e9t\u00e9 mis en place le traitement de suppl\u00e9ance\u00a0:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_12_46' type='text' value='' class='large'    placeholder='R\u00e9pondez ici..' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_47\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_47'>D\u00e9partement de l\u2019\u00e9tablissement\u00a0:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_12_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>S\u00e9lectionnez<\/option><option value='01 \u2013 Ain' >01 \u2013 Ain<\/option><option value='02 \u2013 Aisne' >02 \u2013 Aisne<\/option><option value='03 \u2013 Allier' >03 \u2013 Allier<\/option><option value='04 \u2013 Alpes de Haute Provence' >04 \u2013 Alpes de Haute Provence<\/option><option value='05 \u2013 Hautes Alpes' >05 \u2013 Hautes Alpes<\/option><option value='06 \u2013 Alpes Maritimes' >06 \u2013 Alpes Maritimes<\/option><option value='07 \u2013 Ard\u00e8che' >07 \u2013 Ard\u00e8che<\/option><option value='08 \u2013 Ardennes' >08 \u2013 Ardennes<\/option><option value='09 \u2013 Ari\u00e8ge' >09 \u2013 Ari\u00e8ge<\/option><option value='10 \u2013 Aube' >10 \u2013 Aube<\/option><option value='11 \u2013 Aude' >11 \u2013 Aude<\/option><option value='12 \u2013 Aveyron' >12 \u2013 Aveyron<\/option><option value='13 \u2013 Bouches du Rh\u00f4ne' >13 \u2013 Bouches du Rh\u00f4ne<\/option><option value='14 \u2013 Calvados' >14 \u2013 Calvados<\/option><option value='15 \u2013 Cantal' >15 \u2013 Cantal<\/option><option value='16 \u2013 Charente' >16 \u2013 Charente<\/option><option value='17 \u2013 Charente Maritime' >17 \u2013 Charente Maritime<\/option><option value='18 \u2013 Cher' >18 \u2013 Cher<\/option><option value='19 \u2013 Corr\u00e8ze' >19 \u2013 Corr\u00e8ze<\/option><option value='20 A \u2013 Corse du Sud' >20 A \u2013 Corse du Sud<\/option><option value='20 B- Haute Corse' >20 B- Haute Corse<\/option><option value='21 \u2013 C\u00f4te d\u2019Or' >21 \u2013 C\u00f4te d\u2019Or<\/option><option value='22 \u2013 C\u00f4tes d\u2019Armor' >22 \u2013 C\u00f4tes d\u2019Armor<\/option><option value='23 \u2013 Creuse' >23 \u2013 Creuse<\/option><option value='24 \u2013 Dordogne' >24 \u2013 Dordogne<\/option><option value='25 \u2013 Doubs' >25 \u2013 Doubs<\/option><option value='26 \u2013 Dr\u00f4me' >26 \u2013 Dr\u00f4me<\/option><option value='27 \u2013 Eure' >27 \u2013 Eure<\/option><option value='28 \u2013 Eure et Loir' >28 \u2013 Eure et Loir<\/option><option value='29 \u2013 Finist\u00e8re' >29 \u2013 Finist\u00e8re<\/option><option value='30 \u2013 Gard' >30 \u2013 Gard<\/option><option value='31 \u2013 Haute Garonne' >31 \u2013 Haute Garonne<\/option><option value='32 \u2013 Gers' >32 \u2013 Gers<\/option><option value='33 \u2013 Gironde' >33 \u2013 Gironde<\/option><option value='34 \u2013 H\u00e9rault' >34 \u2013 H\u00e9rault<\/option><option value='35 \u2013 Ille et Vilaine' >35 \u2013 Ille et Vilaine<\/option><option value='36 \u2013 Indre' >36 \u2013 Indre<\/option><option value='37 \u2013 Indre et Loire' >37 \u2013 Indre et Loire<\/option><option value='38 \u2013 Is\u00e8re' >38 \u2013 Is\u00e8re<\/option><option value='39 \u2013 Jura' >39 \u2013 Jura<\/option><option value='40 \u2013 Landes' >40 \u2013 Landes<\/option><option value='41 \u2013 Loir et Cher' >41 \u2013 Loir et Cher<\/option><option value='42 \u2013 Loire' >42 \u2013 Loire<\/option><option value='43 \u2013 Haute Loire' >43 \u2013 Haute Loire<\/option><option value='44 \u2013 Loire Atlantique' >44 \u2013 Loire Atlantique<\/option><option value='45 \u2013 Loiret' >45 \u2013 Loiret<\/option><option value='46 \u2013 Lot' >46 \u2013 Lot<\/option><option value='47 \u2013 Lot et Garonne' >47 \u2013 Lot et Garonne<\/option><option value='48 \u2013 Loz\u00e8re' >48 \u2013 Loz\u00e8re<\/option><option value='49 \u2013 Maine et Loire' >49 \u2013 Maine et Loire<\/option><option value='50 \u2013 Manche' >50 \u2013 Manche<\/option><option value='51 \u2013 Marne' >51 \u2013 Marne<\/option><option value='52 \u2013 Haute Marne' >52 \u2013 Haute Marne<\/option><option value='53 \u2013 Mayenne' >53 \u2013 Mayenne<\/option><option value='54 \u2013 Meurthe et Moselle' >54 \u2013 Meurthe et Moselle<\/option><option value='55 \u2013 Meuse' >55 \u2013 Meuse<\/option><option value='56 \u2013 Morbihan' >56 \u2013 Morbihan<\/option><option value='57 \u2013 Moselle' >57 \u2013 Moselle<\/option><option value='58 \u2013 Ni\u00e8vre' >58 \u2013 Ni\u00e8vre<\/option><option value='59 \u2013 Nord' >59 \u2013 Nord<\/option><option value='60 \u2013 Oise' >60 \u2013 Oise<\/option><option value='61 \u2013 Orne' >61 \u2013 Orne<\/option><option value='62 \u2013 Pas de Calais' >62 \u2013 Pas de Calais<\/option><option value='63 \u2013 Puy de D\u00f4me' >63 \u2013 Puy de D\u00f4me<\/option><option value='64 \u2013 Pyr\u00e9n\u00e9es Atlantiques' >64 \u2013 Pyr\u00e9n\u00e9es Atlantiques<\/option><option value='65 \u2013 Hautes Pyr\u00e9n\u00e9es' >65 \u2013 Hautes Pyr\u00e9n\u00e9es<\/option><option value='66 \u2013 Pyr\u00e9n\u00e9es Orientales' >66 \u2013 Pyr\u00e9n\u00e9es Orientales<\/option><option value='67\/68 \u2013 Collectivit\u00e9 Europ\u00e9enne d\u2019Alsace (CEA)' >67\/68 \u2013 Collectivit\u00e9 Europ\u00e9enne d\u2019Alsace (CEA)<\/option><option value='69 \u2013 Rh\u00f4ne' >69 \u2013 Rh\u00f4ne<\/option><option value='69 M- M\u00e9tropole de Lyon' >69 M- M\u00e9tropole de Lyon<\/option><option value='70 \u2013 Haute Sa\u00f4ne' >70 \u2013 Haute Sa\u00f4ne<\/option><option value='71 \u2013 Sa\u00f4ne et Loire' >71 \u2013 Sa\u00f4ne et Loire<\/option><option value='72 \u2013 Sarthe' >72 \u2013 Sarthe<\/option><option value='73 \u2013 Savoie' >73 \u2013 Savoie<\/option><option value='74 \u2013 Haute Savoie' >74 \u2013 Haute Savoie<\/option><option value='75 \u2013 Paris' >75 \u2013 Paris<\/option><option value='76 \u2013 Seine Maritime' >76 \u2013 Seine Maritime<\/option><option value='77 \u2013 Seine et Marne' >77 \u2013 Seine et Marne<\/option><option value='78 \u2013 Yvelines' >78 \u2013 Yvelines<\/option><option value='79 \u2013 Deux S\u00e8vres' >79 \u2013 Deux S\u00e8vres<\/option><option value='80 \u2013 Somme' >80 \u2013 Somme<\/option><option value='81 \u2013 Tarn' >81 \u2013 Tarn<\/option><option value='82 \u2013 Tarn et Garonne' >82 \u2013 Tarn et Garonne<\/option><option value='83 \u2013 Var' >83 \u2013 Var<\/option><option value='84 \u2013 Vaucluse' >84 \u2013 Vaucluse<\/option><option value='85 \u2013 Vend\u00e9e' >85 \u2013 Vend\u00e9e<\/option><option value='86 \u2013 Vienne' >86 \u2013 Vienne<\/option><option value='87 \u2013 Haute Vienne' >87 \u2013 Haute Vienne<\/option><option value='88 \u2013 Vosges' >88 \u2013 Vosges<\/option><option value='89 \u2013 Yonne' >89 \u2013 Yonne<\/option><option value='90 \u2013 Territoire de Belfort' >90 \u2013 Territoire de Belfort<\/option><option value='91 \u2013 Essonne' >91 \u2013 Essonne<\/option><option value='92 \u2013 Hauts de Seine' >92 \u2013 Hauts de Seine<\/option><option value='93 \u2013 Seine Saint Denis' >93 \u2013 Seine Saint Denis<\/option><option value='94 \u2013 Val de Marne' >94 \u2013 Val de Marne<\/option><option value='95 \u2013 Val D\u2019Oise' >95 \u2013 Val D\u2019Oise<\/option><option value='971 \u2013 Guadeloupe' >971 \u2013 Guadeloupe<\/option><option value='972 \u2013 Martinique' >972 \u2013 Martinique<\/option><option value='973 \u2013 Guyane' >973 \u2013 Guyane<\/option><option value='974 \u2013 La R\u00e9union' >974 \u2013 La R\u00e9union<\/option><option value='976 \u2013 Mayotte' >976 \u2013 Mayotte<\/option><option value='988 \u2013 Province Sud de la Nouvelle Cal\u00e9donie' >988 \u2013 Province Sud de la Nouvelle Cal\u00e9donie<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_44' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_44' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_7' class='gform_page' data-js='page-field-id-44' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_7' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_50'>Quelle est la marque du moniteur de dialyse \u00e0 domicile\u00a0?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_12_50' type='text' value='' class='large'    placeholder='R\u00e9pondez ici..' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_51'>Etablissement o\u00f9 a \u00e9t\u00e9 mis en place la dialyse \u00e0 domicile :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_12_51' type='text' value='' class='large'    placeholder='R\u00e9pondez ici..' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_52\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_52'>D\u00e9partement de l\u2019\u00e9tablissement\u00a0:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_12_52' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>S\u00e9lectionnez<\/option><option value='01 \u2013 Ain' >01 \u2013 Ain<\/option><option value='02 \u2013 Aisne' >02 \u2013 Aisne<\/option><option value='03 \u2013 Allier' >03 \u2013 Allier<\/option><option value='04 \u2013 Alpes de Haute Provence' >04 \u2013 Alpes de Haute Provence<\/option><option value='05 \u2013 Hautes Alpes' >05 \u2013 Hautes Alpes<\/option><option value='06 \u2013 Alpes Maritimes' >06 \u2013 Alpes Maritimes<\/option><option value='07 \u2013 Ard\u00e8che' >07 \u2013 Ard\u00e8che<\/option><option value='08 \u2013 Ardennes' >08 \u2013 Ardennes<\/option><option value='09 \u2013 Ari\u00e8ge' >09 \u2013 Ari\u00e8ge<\/option><option value='10 \u2013 Aube' >10 \u2013 Aube<\/option><option value='11 \u2013 Aude' >11 \u2013 Aude<\/option><option value='12 \u2013 Aveyron' >12 \u2013 Aveyron<\/option><option value='13 \u2013 Bouches du Rh\u00f4ne' >13 \u2013 Bouches du Rh\u00f4ne<\/option><option value='14 \u2013 Calvados' >14 \u2013 Calvados<\/option><option value='15 \u2013 Cantal' >15 \u2013 Cantal<\/option><option value='16 \u2013 Charente' >16 \u2013 Charente<\/option><option value='17 \u2013 Charente Maritime' >17 \u2013 Charente Maritime<\/option><option value='18 \u2013 Cher' >18 \u2013 Cher<\/option><option value='19 \u2013 Corr\u00e8ze' >19 \u2013 Corr\u00e8ze<\/option><option value='20 A \u2013 Corse du Sud' >20 A \u2013 Corse du Sud<\/option><option value='20 B- Haute Corse' >20 B- Haute Corse<\/option><option value='21 \u2013 C\u00f4te d\u2019Or' >21 \u2013 C\u00f4te d\u2019Or<\/option><option value='22 \u2013 C\u00f4tes d\u2019Armor' >22 \u2013 C\u00f4tes d\u2019Armor<\/option><option value='23 \u2013 Creuse' >23 \u2013 Creuse<\/option><option value='24 \u2013 Dordogne' >24 \u2013 Dordogne<\/option><option value='25 \u2013 Doubs' >25 \u2013 Doubs<\/option><option value='26 \u2013 Dr\u00f4me' >26 \u2013 Dr\u00f4me<\/option><option value='27 \u2013 Eure' >27 \u2013 Eure<\/option><option value='28 \u2013 Eure et Loir' >28 \u2013 Eure et Loir<\/option><option value='29 \u2013 Finist\u00e8re' >29 \u2013 Finist\u00e8re<\/option><option value='30 \u2013 Gard' >30 \u2013 Gard<\/option><option value='31 \u2013 Haute Garonne' >31 \u2013 Haute Garonne<\/option><option value='32 \u2013 Gers' >32 \u2013 Gers<\/option><option value='33 \u2013 Gironde' >33 \u2013 Gironde<\/option><option value='34 \u2013 H\u00e9rault' >34 \u2013 H\u00e9rault<\/option><option value='35 \u2013 Ille et Vilaine' >35 \u2013 Ille et Vilaine<\/option><option value='36 \u2013 Indre' >36 \u2013 Indre<\/option><option value='37 \u2013 Indre et Loire' >37 \u2013 Indre et Loire<\/option><option value='38 \u2013 Is\u00e8re' >38 \u2013 Is\u00e8re<\/option><option value='39 \u2013 Jura' >39 \u2013 Jura<\/option><option value='40 \u2013 Landes' >40 \u2013 Landes<\/option><option value='41 \u2013 Loir et Cher' >41 \u2013 Loir et Cher<\/option><option value='42 \u2013 Loire' >42 \u2013 Loire<\/option><option value='43 \u2013 Haute Loire' >43 \u2013 Haute Loire<\/option><option value='44 \u2013 Loire Atlantique' >44 \u2013 Loire Atlantique<\/option><option value='45 \u2013 Loiret' >45 \u2013 Loiret<\/option><option value='46 \u2013 Lot' >46 \u2013 Lot<\/option><option value='47 \u2013 Lot et Garonne' >47 \u2013 Lot et Garonne<\/option><option value='48 \u2013 Loz\u00e8re' >48 \u2013 Loz\u00e8re<\/option><option value='49 \u2013 Maine et Loire' >49 \u2013 Maine et Loire<\/option><option value='50 \u2013 Manche' >50 \u2013 Manche<\/option><option value='51 \u2013 Marne' >51 \u2013 Marne<\/option><option value='52 \u2013 Haute Marne' >52 \u2013 Haute Marne<\/option><option value='53 \u2013 Mayenne' >53 \u2013 Mayenne<\/option><option value='54 \u2013 Meurthe et Moselle' >54 \u2013 Meurthe et Moselle<\/option><option value='55 \u2013 Meuse' >55 \u2013 Meuse<\/option><option value='56 \u2013 Morbihan' >56 \u2013 Morbihan<\/option><option value='57 \u2013 Moselle' >57 \u2013 Moselle<\/option><option value='58 \u2013 Ni\u00e8vre' >58 \u2013 Ni\u00e8vre<\/option><option value='59 \u2013 Nord' >59 \u2013 Nord<\/option><option value='60 \u2013 Oise' >60 \u2013 Oise<\/option><option value='61 \u2013 Orne' >61 \u2013 Orne<\/option><option value='62 \u2013 Pas de Calais' >62 \u2013 Pas de Calais<\/option><option value='63 \u2013 Puy de D\u00f4me' >63 \u2013 Puy de D\u00f4me<\/option><option value='64 \u2013 Pyr\u00e9n\u00e9es Atlantiques' >64 \u2013 Pyr\u00e9n\u00e9es Atlantiques<\/option><option value='65 \u2013 Hautes Pyr\u00e9n\u00e9es' >65 \u2013 Hautes Pyr\u00e9n\u00e9es<\/option><option value='66 \u2013 Pyr\u00e9n\u00e9es Orientales' >66 \u2013 Pyr\u00e9n\u00e9es Orientales<\/option><option value='67\/68 \u2013 Collectivit\u00e9 Europ\u00e9enne d\u2019Alsace (CEA)' >67\/68 \u2013 Collectivit\u00e9 Europ\u00e9enne d\u2019Alsace (CEA)<\/option><option value='69 \u2013 Rh\u00f4ne' >69 \u2013 Rh\u00f4ne<\/option><option value='69 M- M\u00e9tropole de Lyon' >69 M- M\u00e9tropole de Lyon<\/option><option value='70 \u2013 Haute Sa\u00f4ne' >70 \u2013 Haute Sa\u00f4ne<\/option><option value='71 \u2013 Sa\u00f4ne et Loire' >71 \u2013 Sa\u00f4ne et Loire<\/option><option value='72 \u2013 Sarthe' >72 \u2013 Sarthe<\/option><option value='73 \u2013 Savoie' >73 \u2013 Savoie<\/option><option value='74 \u2013 Haute Savoie' >74 \u2013 Haute Savoie<\/option><option value='75 \u2013 Paris' >75 \u2013 Paris<\/option><option value='76 \u2013 Seine Maritime' >76 \u2013 Seine Maritime<\/option><option value='77 \u2013 Seine et Marne' >77 \u2013 Seine et Marne<\/option><option value='78 \u2013 Yvelines' >78 \u2013 Yvelines<\/option><option value='79 \u2013 Deux S\u00e8vres' >79 \u2013 Deux S\u00e8vres<\/option><option value='80 \u2013 Somme' >80 \u2013 Somme<\/option><option value='81 \u2013 Tarn' >81 \u2013 Tarn<\/option><option value='82 \u2013 Tarn et Garonne' >82 \u2013 Tarn et Garonne<\/option><option value='83 \u2013 Var' >83 \u2013 Var<\/option><option value='84 \u2013 Vaucluse' >84 \u2013 Vaucluse<\/option><option value='85 \u2013 Vend\u00e9e' >85 \u2013 Vend\u00e9e<\/option><option value='86 \u2013 Vienne' >86 \u2013 Vienne<\/option><option value='87 \u2013 Haute Vienne' >87 \u2013 Haute Vienne<\/option><option value='88 \u2013 Vosges' >88 \u2013 Vosges<\/option><option value='89 \u2013 Yonne' >89 \u2013 Yonne<\/option><option value='90 \u2013 Territoire de Belfort' >90 \u2013 Territoire de Belfort<\/option><option value='91 \u2013 Essonne' >91 \u2013 Essonne<\/option><option value='92 \u2013 Hauts de Seine' >92 \u2013 Hauts de Seine<\/option><option value='93 \u2013 Seine Saint Denis' >93 \u2013 Seine Saint Denis<\/option><option value='94 \u2013 Val de Marne' >94 \u2013 Val de Marne<\/option><option value='95 \u2013 Val D\u2019Oise' >95 \u2013 Val D\u2019Oise<\/option><option value='971 \u2013 Guadeloupe' >971 \u2013 Guadeloupe<\/option><option value='972 \u2013 Martinique' >972 \u2013 Martinique<\/option><option value='973 \u2013 Guyane' >973 \u2013 Guyane<\/option><option value='974 \u2013 La R\u00e9union' >974 \u2013 La R\u00e9union<\/option><option value='976 \u2013 Mayotte' >976 \u2013 Mayotte<\/option><option value='988 \u2013 Province Sud de la Nouvelle Cal\u00e9donie' >988 \u2013 Province Sud de la Nouvelle Cal\u00e9donie<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_53' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_53' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_8' class='gform_page' data-js='page-field-id-53' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_8' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_12_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Connaissez-vous la dialyse \u00e0 domicile\u00a0?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_54'>\n\t\t\t<div class='gchoice gchoice_12_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Oui'  id='choice_12_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_54_0' id='label_12_54_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Non'  id='choice_12_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_54_1' id='label_12_54_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 eu, vous (ou votre proche), une pr\u00e9sentation de la dialyse \u00e0 domicile dans le cadre du parcours de soin ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_77'>\n\t\t\t<div class='gchoice gchoice_12_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Oui'  id='choice_12_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_77_0' id='label_12_77_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Non'  id='choice_12_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_77_1' id='label_12_77_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_56' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_56' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_9' class='gform_page' data-js='page-field-id-56' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_9' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_12_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Quel(s) interlocuteur(s) vous a permis de conna\u00eetre et de choisir l\u2019h\u00e9modialyse \u00e0 domicile ? (plusieurs r\u00e9ponses possibles)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_12_57'><div class='gchoice gchoice_12_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Votre n\u00e9phrologue'  id='choice_12_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_57_1' id='label_12_57_1' class='gform-field-label gform-field-label--type-inline'>Votre n\u00e9phrologue<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_57_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.2' type='checkbox'  value='L\u2019infirmier(e) responsable de votre information pr\u00e9-suppl\u00e9ance'  id='choice_12_57_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_57_2' id='label_12_57_2' class='gform-field-label gform-field-label--type-inline'>L\u2019infirmier(e) responsable de votre information pr\u00e9-suppl\u00e9ance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_57_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.3' type='checkbox'  value='Vous-m\u00eame, par votre volont\u00e9 de rester \u00e0 domicile'  id='choice_12_57_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_57_3' id='label_12_57_3' class='gform-field-label gform-field-label--type-inline'>Vous-m\u00eame, par votre volont\u00e9 de rester \u00e0 domicile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_57_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.4' type='checkbox'  value='Le support de votre entourage'  id='choice_12_57_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_57_4' id='label_12_57_4' class='gform-field-label gform-field-label--type-inline'>Le support de votre entourage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_57_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.5' type='checkbox'  value='Une association de patients'  id='choice_12_57_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_57_5' id='label_12_57_5' class='gform-field-label gform-field-label--type-inline'>Une association de patients<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_57_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.6' type='checkbox'  value='Autre'  id='choice_12_57_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_57_6' id='label_12_57_6' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_57_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_12_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_58'>Autre, merci de pr\u00e9ciser\u00a0:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_12_58' type='text' value='' class='large'    placeholder='R\u00e9pondez ici' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_59' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_10' class='gform_page' data-js='page-field-id-59' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_10' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_12_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Depuis combien de temps utilisez-vous un dispositif de dialyse \u00e0 domicile ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_60'>\n\t\t\t<div class='gchoice gchoice_12_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Moins de 12 mois'  id='choice_12_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_60_0' id='label_12_60_0' class='gform-field-label gform-field-label--type-inline'>Moins de 12 mois<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Entre 1 et 3 ans'  id='choice_12_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_60_1' id='label_12_60_1' class='gform-field-label gform-field-label--type-inline'>Entre 1 et 3 ans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Entre 4 et 9 ans'  id='choice_12_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_60_2' id='label_12_60_2' class='gform-field-label gform-field-label--type-inline'>Entre 4 et 9 ans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='&gt; \u00e0 9 ans'  id='choice_12_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_60_3' id='label_12_60_3' class='gform-field-label gform-field-label--type-inline'>&gt; \u00e0 9 ans<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_61' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_61' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_11' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_11' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_12_62\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Quel est votre parcours avant de b\u00e9n\u00e9ficier de l\u2019h\u00e9modialyse quotidienne \u00e0 domicile ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_12_62'><div class='gchoice gchoice_12_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='J\u2019\u00e9tais en dialyse p\u00e9riton\u00e9ale'  id='choice_12_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_62_1' id='label_12_62_1' class='gform-field-label gform-field-label--type-inline'>J\u2019\u00e9tais en dialyse p\u00e9riton\u00e9ale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='J\u2019\u00e9tais en dialyse en centre'  id='choice_12_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_62_2' id='label_12_62_2' class='gform-field-label gform-field-label--type-inline'>J\u2019\u00e9tais en dialyse en centre<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_62_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.3' type='checkbox'  value='J\u2019ai b\u00e9n\u00e9fici\u00e9 d\u2019une greffe r\u00e9nale'  id='choice_12_62_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_62_3' id='label_12_62_3' class='gform-field-label gform-field-label--type-inline'>J\u2019ai b\u00e9n\u00e9fici\u00e9 d\u2019une greffe r\u00e9nale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_62_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.4' type='checkbox'  value='J\u2019\u00e9tais sur un autre syst\u00e8me d\u2019h\u00e9modialyse \u00e0 domicile'  id='choice_12_62_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_62_4' id='label_12_62_4' class='gform-field-label gform-field-label--type-inline'>J\u2019\u00e9tais sur un autre syst\u00e8me d\u2019h\u00e9modialyse \u00e0 domicile<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_62_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.5' type='checkbox'  value='J\u2019\u00e9tais sur un autre syst\u00e8me d\u2019h\u00e9modialyse quotidienne \u00e0 domicile que Physidia S3'  id='choice_12_62_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_62_5' id='label_12_62_5' class='gform-field-label gform-field-label--type-inline'>J\u2019\u00e9tais sur un autre syst\u00e8me d\u2019h\u00e9modialyse quotidienne \u00e0 domicile que Physidia S3<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_62_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.6' type='checkbox'  value='Autre'  id='choice_12_62_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_62_6' id='label_12_62_6' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_62_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_12_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_70'>Autre, merci de pr\u00e9ciser\u00a0:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_12_70' type='text' value='' class='large'    placeholder='R\u00e9pondez ici' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_74' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_74' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_12' class='gform_page' data-js='page-field-id-74' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_12' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_72'>Email sur lequel nous pouvons-vous contacter\u00a0:<\/label><div class='gfield_description' id='gfield_description_12_72'>Vous pouvez changer d\u2019avis \u00e0 tout moment et vous inscrire\/d\u00e9sinscrire sur le site www.nehomy.com<\/div><div class='ginput_container ginput_container_text'><input name='input_72' id='input_12_72' type='text' value='' class='large'  aria-describedby=\"gfield_description_12_72\"  placeholder='Email'  aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_12_67' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_12_67' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_12_13' class='gform_page' data-js='page-field-id-67' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_12_13' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_12_69\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p>Nehomy fait preuve de transparence quant \u00e0 la mani\u00e8re dont nous utilisons vos donn\u00e9es personnelles. En cr\u00e9ant votre espace priv\u00e9, vous consentez, conform\u00e9ment au RGPD, \u00e0 ce que vos donn\u00e9es personnelles (pr\u00e9nom, nom et adresse e-mail) soient recueillis et fassent l\u2019objet d\u2019un traitement manuel par Nehomy.<\/p>\n<p style=\"font-style:italic;\"><strong>Vous informer sur la protection de vos donn\u00e9es\u00a0: RGPD et Loi informatique et libert\u00e9s<\/strong><br>\nLes informations recueillies sur ce formulaire sont enregistr\u00e9es par Nehomy de fa\u00e7on anonyme, confidentielle et s\u00e9curis\u00e9e. Les donn\u00e9es sont conserv\u00e9es pendant une ann\u00e9e.<\/p>\n<p>Les donn\u00e9es sont conserv\u00e9es pendant\u00a0une ann\u00e9e, sous r\u00e9serve que ces donn\u00e9es ne soient d\u00e9j\u00e0 r\u00e9colt\u00e9es et utilis\u00e9es dans le cadre d'obligations l\u00e9gales, comme des contrats, conventions ou autres. Vous pouvez acc\u00e9der aux donn\u00e9es vous concernant, les rectifier, demander leur effacement ou exercer votre droit \u00e0 la limitation du traitement de vos donn\u00e9es.<\/p>\n<p style=\"font-style:italic;\">Pour exercer vos droits sur vos donn\u00e9es ou pour toute question sur le traitement de vos donn\u00e9es dans ce dispositif, vous pouvez contacter\u00a0le D\u00e9l\u00e9gu\u00e9 \u00e0 la protection des Donn\u00e9es de Nehomy \u00e0 l\u2019adresse \u00e9lectronique suivante :\u00a0dpo@physidia.fr\u00a0, ou par voie postale \u00e0\u00a0: \u00a0Nehomy, 11\/13 avenue des Bretonni\u00e8res, 49124 Saint Barth\u00e9l\u00e9my d'Anjou.<\/p><p style=\"font-style:italic;\">Pour exercer ces droits ou pour toute question sur le traitement de vos donn\u00e9es dans ce dispositif, vous pouvez contacter\u00a0le service charg\u00e9 de l\u2019exercice de ces droits : dpo@physidia.fr - Nehomy, 11\/13 avenue des Bretonni\u00e8res, 49124 Saint Barth\u00e9l\u00e9my d'Anjou.<br>Si vous estimez, apr\u00e8s nous avoir contact\u00e9s, que vos droits \u00ab\u00a0Informatique et Libert\u00e9s\u00a0\u00bb ne sont pas respect\u00e9s, vous pouvez adresser une r\u00e9clamation \u00e0 la CNIL. Consultez le site\u00a0cnil.fr\u00a0pour plus d\u2019informations sur vos droits.<\/p><\/div><fieldset id=\"field_12_79\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >RGPD<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_79.1' id='input_12_79_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_12_79_1' >J\u2019accepte <a href=\"\/politique-de-confidentialite\/\" target=\"_blank\">la politique de confidentialit\u00e9<\/a> de Nehomy et 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