{"id":142,"date":"2017-09-06T13:03:35","date_gmt":"2017-09-06T12:03:35","guid":{"rendered":"https:\/\/mes-formulaires.cpamcentre.fr\/?page_id=142"},"modified":"2017-09-06T13:03:35","modified_gmt":"2017-09-06T12:03:35","slug":"inscription-123-mangeons","status":"publish","type":"page","link":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/inscription-123-mangeons\/","title":{"rendered":"Inscription \u00e0 l&rsquo;accompagnement \u00ab\u00a01, 2, 3&#8230; Mangeons !\u00a0\u00bb"},"content":{"rendered":"<p style=\"text-align: justify;\">Le Centre d\u2019Examens de Sant\u00e9 de Blois vous propose une offre d\u2019accompagnement pour vos jeunes patients (enfants et adolescents de 5 \u00e0 15 ans inclus) en situation de surpoids\u00a0: 1, 2, 3&#8230; Mangeons !\u00a0Ensemble, aidons-les \u00e0 d\u00e9couvrir le plaisir de grandir en mangeant \u00e9quilibr\u00e9.<\/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-f143-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"143\">\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\/142#wpcf7-f143-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=\"143\" \/>\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-f143-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 de l'enfant*<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 de l'enfant*<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>\u00c2ge*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Age\"><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=\"Age\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Taille*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Taille\"><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=\"Taille\" \/><\/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>Poids*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Poids\"><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=\"Poids\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>IMC*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"IMC\"><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=\"IMC\" \/><\/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>&nbsp;\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<p>Nom des parents*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomParents\"><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=\"NomParents\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td style=\"padding-left:30px;\">\n\t\t\t<p>Telephone*<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\t<tr>\n\t\t<td>\n\t\t\t<p>Adresse compl\u00e8te*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Adresse\"><textarea cols=\"42\" rows=\"4\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Adresse\"><\/textarea><\/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<\/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;accompagnement 1, 2, 3... Mangeons !\" \/><span class=\"wpcf7-list-item-label\">Je donne mon accord pour la participation de mon patient au programme d&#039;accompagnement 1, 2, 3... Mangeons !<\/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 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=\"3169051572\" \/><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\/3169051572.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=\"136\"\/><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 Centre d\u2019Examens de Sant\u00e9 de Blois vous propose une offre d\u2019accompagnement pour vos jeunes patients (enfants et adolescents de 5 \u00e0 15 ans inclus) en situation de surpoids\u00a0: 1, 2, 3&#8230; Mangeons !\u00a0Ensemble, aidons-les \u00e0 d\u00e9couvrir le plaisir de grandir en mangeant \u00e9quilibr\u00e9. 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-142","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/142"}],"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=142"}],"version-history":[{"count":1,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/142\/revisions"}],"predecessor-version":[{"id":144,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/142\/revisions\/144"}],"wp:attachment":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/media?parent=142"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}