{"id":137,"date":"2017-09-06T12:06:55","date_gmt":"2017-09-06T11:06:55","guid":{"rendered":"https:\/\/mes-formulaires.cpamcentre.fr\/?page_id=137"},"modified":"2017-09-06T12:13:06","modified_gmt":"2017-09-06T11:13:06","slug":"inscription-etp-diabete","status":"publish","type":"page","link":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/inscription-etp-diabete\/","title":{"rendered":"Inscription au programme nationnal d&rsquo;\u00e9ducation th\u00e9rapeutique des patients diab\u00e9tiques de type 2"},"content":{"rendered":"<p style=\"text-align: justify;\">Le\u00a0Centre d\u2019Examens de Sant\u00e9 de Blois propose de suivre un programme d&rsquo;\u00e9ducation th\u00e9rapeutique pour les patients diab\u00e9tiques de type 2, durant lequel ils peuvent partager leur\u00a0exp\u00e9rience avec d\u2019autres personnes diab\u00e9tiques et, \u00e0 leur\u00a0rythme, trouver les solutions pour changer leurs habitudes (alimentation et activit\u00e9 physique).<\/p>\n<p style=\"text-align: justify;\">Pour inscrire gratuitement\u00a0votre patient(e), compl\u00e9tez le formulaire d&rsquo;accord du m\u00e9decin traitant ci-dessous.<\/p>\n<hr \/>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f136-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"136\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/137#wpcf7-f136-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"136\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f136-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<table border=0 padding=0 margin=0>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>Vos informations m\u00e9decin traitant\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomMT\"><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=\"NomMT\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Pr\u00e9nom*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PrenomMT\"><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=\"PrenomMT\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>N\u00b0 Identification Assurance Maladie (41...)*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NumAM\"><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=\"NumAM\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Adresse mail*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"MailMT\"><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=\"MailMT\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>T\u00e9l\u00e9phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"TelephoneMT\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"TelephoneMT\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<h4>&nbsp;<br \/>\nInformations sur le patient\n\t\t\t<\/h4>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Nom du patient*<br \/>\n<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>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Pr\u00e9nom*<br \/>\n<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>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td>\n\t\t\t<p>Date de naissance*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateNaissance\"><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=\"DateNaissance\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>T\u00e9l\u00e9phone*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Telephone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"Telephone\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table>\n<table>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p>&nbsp;\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"AccordMT\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"AccordMT[]\" value=\"Je donne mon accord pour la participation de mon patient au programme d&#039;\u00e9ducation th\u00e9rapeutique des patients diab\u00e9tiques de type 2.\" \/><span class=\"wpcf7-list-item-label\">Je donne mon accord pour la participation de mon patient au programme d&#039;\u00e9ducation th\u00e9rapeutique des patients diab\u00e9tiques de type 2.<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p>En validant ce formulaire, <strong>je certifie que mon patient :<\/strong>\n\t\t\t<\/p>\n\t\t\t<ul style=\"margin-top:-30px;\">\n\t\t\t\t<li>\n\t\t\t\t\t<p>A entre 30 et 75 ans ;\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Est b\u00e9n\u00e9ficiaire du r\u00e9gime g\u00e9n\u00e9ral de l'Assurance Maladie ;\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>Est diab\u00e9tique de type 2 (<= 2 injections d'insuline par jour) ;\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t\t<li>\n\t\t\t\t\t<p>N'a pas particip\u00e9 \u00e0 un programme d'\u00e9ducation th\u00e9rapeutique dans les 2 ans qui pr\u00e9c\u00e8dent.\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/li>\n\t\t\t<\/ul>\n\t\t<\/td>\n\t<\/tr>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center>&nbsp;<br \/>\n<i>L'envoi par mail vaut signature<\/i>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n\t<table>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><b>Merci de saisir le code affich\u00e9 ci-dessous pour valider votre envoi : <\/b><br \/>\n<input type=\"hidden\" name=\"_wpcf7_captcha_challenge_captcha-170\" value=\"2493208108\" \/><img decoding=\"async\" class=\"wpcf7-form-control wpcf7-captchac wpcf7-captcha-captcha-170\" width=\"72\" height=\"24\" alt=\"captcha\" src=\"https:\/\/mes-formulaires.cpamcentre.fr\/wp-content\/uploads\/wpcf7_captcha\/2493208108.png\" \/><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"captcha-170\"><input size=\"4\" maxlength=\"4\" class=\"wpcf7-form-control wpcf7-captchar\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"captcha-170\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/table>\n\t<tr>\n\t\t<td style=\"padding:0;margin:0;\">\n\t\t\t<p align=center><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/tr>\n<\/table><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_1\" name=\"_wpcf7_ak_js\" value=\"246\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>Le\u00a0Centre d\u2019Examens de Sant\u00e9 de Blois propose de suivre un programme d&rsquo;\u00e9ducation th\u00e9rapeutique pour les patients diab\u00e9tiques de type 2, durant lequel ils peuvent partager leur\u00a0exp\u00e9rience avec d\u2019autres personnes diab\u00e9tiques et, \u00e0 leur\u00a0rythme, trouver les solutions pour changer leurs habitudes (alimentation et activit\u00e9 physique). Pour inscrire gratuitement\u00a0votre patient(e), compl\u00e9tez le formulaire d&rsquo;accord du m\u00e9decin traitant ci-dessous.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-137","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/137"}],"collection":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/comments?post=137"}],"version-history":[{"count":4,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/137\/revisions"}],"predecessor-version":[{"id":139,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/137\/revisions\/139"}],"wp:attachment":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/media?parent=137"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}