{"id":6161,"date":"2024-09-16T14:09:12","date_gmt":"2024-09-16T12:09:12","guid":{"rendered":"https:\/\/www.serveisclinics.com\/effectuez-un-paiement-etoda-de-groupe-non-cohabitant\/"},"modified":"2026-09-26T13:55:45","modified_gmt":"2026-09-26T11:55:45","slug":"effectuez-un-paiement-etoda-de-groupe-non-cohabitant","status":"publish","type":"page","link":"https:\/\/www.serveisclinics.com\/fr\/effectuez-un-paiement-etoda-de-groupe-non-cohabitant\/","title":{"rendered":"Demande d\u2019admission group\u00e9e \u00e0 l\u2019ETODA \u2013 personnes ne vivant pas sous le m\u00eame toit"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6161\" class=\"elementor elementor-6161 elementor-2452\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-19ca585 e-flex e-con-boxed e-con e-child\" data-id=\"19ca585\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6114352 elementor-widget elementor-widget-heading\" data-id=\"6114352\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Demande d\u2019admission<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-3444b3e e-flex e-con-boxed e-con e-parent\" data-id=\"3444b3e\" 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\t\t<div class=\"elementor-element elementor-element-5263eb9 bold elementor-widget elementor-widget-heading\" data-id=\"5263eb9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Formulaire ETODA \u2013 Admission group\u00e9e de personnes ne vivant pas sous le m\u00eame toit<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4507933 e-flex e-con-boxed e-con e-parent\" data-id=\"4507933\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ed87abf elementor-widget elementor-widget-shortcode\" data-id=\"ed87abf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f7019-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"7019\">\n<div class=\"screen-reader-response\"><p role=\"status\" 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name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" 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\/><input type=\"hidden\" name=\"_uacf7_hidden_conditional_fields\" value=\"\" \/>\n<\/fieldset>\n\t\t\t\t<style>\n\t\t\t\t\t.uacf7-uacf7style-7019 label {\n\t\t\t\t\t\tcolor: #000000;background-color: #ffffff;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: 500;margin-top: 20px;margin-bottom: 15px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"email\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"number\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"password\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"search\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"tel\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"text\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"url\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"date\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"radio\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"checkbox\"],\n\t\t\t\t\t.uacf7-uacf7style-7019 select,\n\t\t\t\t\t.uacf7-uacf7style-7019 textarea {\n\t\t\t\t\t\tcolor: #000000;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: normal;border-width: 1px !important;border-color: #1e73be !important;border-style: solid!important;border-radius: 5px;margin-top: 20px;margin-bottom: 15px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7019 .wpcf7-radio span,\n\t\t\t\t\t.uacf7-uacf7style-7019 .wpcf7-checkbox span {\n\t\t\t\t\t\tcolor: #000000;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: normal;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7019 textarea {\n\t\t\t\t\t\t\t\t\t\t\t}\n\n\t\t\t\t\t.wpcf7-form-control-wrap select {\n\t\t\t\t\t\twidth: 100%;\n\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"submit\"] {\n\t\t\t\t\t\tcolor: #ffffff;background-color: #1e73be;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: normal;border-width: 1px;border-color: #1e73be;border-style: solid;border-radius: 5px;margin-top: 20px;margin-bottom: 15px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7019 input[type=\"submit\"]:hover {\n\t\t\t\t\t\tcolor: #000000;background-color: #ffffff;border-color: #1e73be;\t\t\t\t\t}\n\n\t\t\t\t\t\t\t\t\t<\/style>\n\n\t\t\t\t<div class=\"uacf7-uacf7style uacf7-uacf7style-7019\"><div class=\"uacf7-form-wrapper-container uacf7-form-7019  uacf7-uacf7style uacf7-uacf7style-7019\"><label style=\"font-size: 20px;font-weight: 600\">Donn\u00e9es du demandeur<\/label>\n<div class=\"uacf7-row\">\n\n<div class=\"uacf7-col-4\"> \n<label>Date de la demande d'admission*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-solicitud-ingres\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-solicitud-ingres\" \/><\/span><\/label>\n\n<label> T\u00e9l\u00e9phone de contact de la personne qui demande l'admission*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"telefon-solicitant\"><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=\"telefon-solicitant\" \/><\/span> <\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label> Personne qui demande l'admission*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"nom-solicitant\"><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-solicitant\" \/><\/span> <\/label>\n\n<label> Adresse e-mail de la personne qui demande l'admission*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"correu-solicitant\"><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=\"correu-solicitant\" \/><\/span> <\/label> <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label> H\u00f4pital ou centre de r\u00e9f\u00e9rence*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"centre-referencia\"><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=\"centre-referencia\" \/><\/span> <\/label>\n <\/div>\n\n<\/div>\n\n<label style=\"margin-left:-15px\"><span class=\"wpcf7-form-control-wrap\" data-name=\"mostrar-camps-opcionals\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"mostrar-camps-opcionals\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">Ajouter des informations suppl\u00e9mentaires.<\/span><\/label><\/span><\/span><\/span><\/label>\n<div data-id=\"group-info-adicional\" data-orig_data_id=\"group-info-adicional\" class=\"\" data-class=\"wpcf7cf_group\">\n<label> Autres num\u00e9ros de t\u00e9l\u00e9phone utiles (Sp\u00e9cialistes):\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"telefons-interes\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefons-interes\" \/><\/span> <\/label>\n<\/div>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:50px\">Donn\u00e9es du patient atteint de TB<\/label>\n<label>Y a-t-il des cas de TB? [Oui\/Non]\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-hi-ha-casos-tb\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"menu-hi-ha-casos-tb\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Oui\">Oui<\/option><option value=\"Non\">Non<\/option><\/select><\/span><\/label>\n<div data-id=\"conditional-group-casos-tb\" data-orig_data_id=\"conditional-group-casos-tb\" class=\"\" data-class=\"wpcf7cf_group\">\n<div data-wpcf7-group-id=\"pacients-TB\" class=\"wpcf7-field-groups \"><div class=\"wpcf7-field-group\">\n\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> <label>Nom et pr\u00e9nom*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom-pacient-TB\"><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-pacient-TB\" \/><\/span><\/label>\n\n<label>Pays de naissance*:\n\t\t<span id=\"uacf7_country_select\" class=\"wpcf7-form-control-wrap pais-neixament-pacient-TB\">\n\n\t\t\t<input id=\"uacf7_countries_pais-neixament-pacient-TB\" type=\"text\" aria-required=\"true\" aria-invalid=\"false\" name=\"pais-neixament-pacient-TB\" class=\"wpcf7-form-control wpcf7-uacf7_country_dropdown wpcf7-validates-as-required uacf7_country_dropdown_with_flag\">\n\n\t\t\t<span><\/span>\n\n\t\t\t<div style=\"display:none;\">\n\t\t\t\t<input type=\"hidden\" id=\"uacf7_countries_pais-neixament-pacient-TB_code\" data-countrycodeinput=\"1\" readonly=\"readonly\" placeholder=\"Selected country code will appear here\" \/>\n\t\t\t<\/div>\n\n\t\t<\/span>\n\t\t<\/label>\n\n<label>Province*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-provincia-pacient-TB\"><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=\"text-provincia-pacient-TB\" \/><\/span>\n<\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n\n<label>T\u00e9l\u00e9phone*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telefon-pacient-TB\"><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=\"telefon-pacient-TB\" \/><\/span><\/label>\n\n<label>Sexe*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Sexe-pacient-TB\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Sexe-pacient-TB\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Homme\">Homme<\/option><option value=\"Femme\">Femme<\/option><\/select><\/span><\/label>\n\n<label>Adresse*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-adreca-pacient-TB\"><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=\"text-adreca-pacient-TB\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>\u00c2ge*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"edat-pacient-TB\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"edat-pacient-TB\" \/><\/span><\/label>\n\n<label>Commune*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-municipi-pacient-TB\"><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=\"text-municipi-pacient-TB\" \/><\/span>\n<\/label>\n <\/div>\n<\/div>\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es m\u00e9dicales<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>Forme de TB*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"forma-TB\"><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=\"forma-TB\" \/><\/span><\/label>\n\n<label>Sch\u00e9ma recommand\u00e9*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pauta-recomenada\"><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=\"pauta-recomenada\" \/><\/span><\/label>\n\n<label>R\u00e9sistances*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"resistencies\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"resistencies\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Oui\">Oui<\/option><option value=\"Non\">Non<\/option><\/select><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Date de d\u00e9but des sympt\u00f4mes*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-inici-simptomes\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-inici-simptomes\" \/><\/span><\/label>\n\n<label>Bacilloscopie initiale*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"bacilloscopia-inicial\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"bacilloscopia-inicial\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Positive\">Positive<\/option><option value=\"N\u00e9gative\">N\u00e9gative<\/option><option value=\"Non r\u00e9alis\u00e9e\">Non r\u00e9alis\u00e9e<\/option><\/select><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\">\n<label>Date de d\u00e9but du traitement*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-inici-tractament\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-inici-tractament\" \/><\/span><\/label>\n\n<label>N\u00e9cessite un isolement*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"aillament\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"aillament\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Oui\">Oui<\/option><option value=\"Non\">Non<\/option><\/select><\/span><\/label>\n <\/div>\n<\/div>\n\n\n<div data-id=\"conditional-group-resistencies-pacient-tb\" data-orig_data_id=\"conditional-group-resistencies-pacient-tb\" class=\"\" data-class=\"wpcf7cf_group\">\n<label>Quelle r\u00e9sistance:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-resistencia\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-resistencia\" \/><\/span><\/label><\/div>\n\n<div data-id=\"conditional-group-dies-aillament-pacient-tb\" data-orig_data_id=\"conditional-group-dies-aillament-pacient-tb\" class=\"\" data-class=\"wpcf7cf_group\">\n<label>Jours d'isolement recommand\u00e9s:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-dies-aillament\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-dies-aillament\" \/><\/span><\/label><\/div>\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es infirmi\u00e8res<\/label>\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-6\"> \n<label>Allergie ou intol\u00e9rance alimentaire*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alergia-intolerancia-alimentaria\"><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=\"alergia-intolerancia-alimentaria\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-6\"> \n<label>Oxyg\u00e9noth\u00e9rapie*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oxigeno-terapia\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oxigeno-terapia\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Oui\">Oui<\/option><option value=\"Non\">Non<\/option><\/select><\/span><\/label>\n <\/div>\n<\/div>\n\n\n<label>Commentaires\n<span class=\"wpcf7-form-control-wrap\" data-name=\"comentaris-pacient-tb\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"comentaris-pacient-tb\"><\/textarea><\/span><\/label>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:50px\">Informations suppl\u00e9mentaires.<\/label>\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:50px\">Donn\u00e9es du patient atteint de TB<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>CIP:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cip-pacient-TB\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cip-pacient-TB\" \/><\/span><\/label>\n\n<label>Pays d'origine (Pays d'o\u00f9 le patient est r\u00e9cemment arriv\u00e9):\n\t\t<span id=\"uacf7_country_select\" class=\"wpcf7-form-control-wrap pais-origen-pacient-TB\">\n\n\t\t\t<input id=\"uacf7_countries_pais-origen-pacient-TB\" type=\"text\" aria-invalid=\"false\" name=\"pais-origen-pacient-TB\" class=\"wpcf7-form-control wpcf7-uacf7_country_dropdown uacf7_country_dropdown_with_flag\">\n\n\t\t\t<span><\/span>\n\n\t\t\t<div style=\"display:none;\">\n\t\t\t\t<input type=\"hidden\" id=\"uacf7_countries_pais-origen-pacient-TB_code\" data-countrycodeinput=\"1\" readonly=\"readonly\" placeholder=\"Selected country code will appear here\" \/>\n\t\t\t<\/div>\n\n\t\t<\/span>\n\t\t<\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Autres num\u00e9ros de t\u00e9l\u00e9phone:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"altres-telefons-pacient-TB\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"altres-telefons-pacient-TB\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Date d'arriv\u00e9e pour vivre en Espagne:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-arribada-espanya-pacient-TB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-arribada-espanya-pacient-TB\" \/><\/span><\/label>\n <\/div>\n<\/div>\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es m\u00e9dicales<\/label>\n\n<label>Facteurs de risque<\/label>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"factors-risc\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"VIH\" \/><span class=\"wpcf7-list-item-label\">VIH<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Diab\u00e8te\" \/><span class=\"wpcf7-list-item-label\">Diab\u00e8te<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Alcoolisme\" \/><span class=\"wpcf7-list-item-label\">Alcoolisme<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Abus de drogues\" \/><span class=\"wpcf7-list-item-label\">Abus de drogues<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Tabagisme\" \/><span class=\"wpcf7-list-item-label\">Tabagisme<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Traitement immunosuppresseur\" \/><span class=\"wpcf7-list-item-label\">Traitement immunosuppresseur<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Autres\" \/><span class=\"wpcf7-list-item-label\">Autres<\/span><\/label><\/span><\/span><\/span>\n\n<label>Allergie et\/ou intol\u00e9rance \u00e0 un m\u00e9dicament\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alergia-intolerancia-medicament\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"alergia-intolerancia-medicament\" \/><\/span><\/label>\n\n\n\n<div data-id=\"conditional-group-factors-risc\" data-orig_data_id=\"conditional-group-factors-risc\" class=\"\" data-class=\"wpcf7cf_group\">\n<label>Pr\u00e9ciser les autres:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"factors-risc-altres\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"factors-risc-altres\" \/><\/span><\/label><\/div>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es infirmi\u00e8res<\/label>\n\n<label>Barthel\n<span class=\"wpcf7-form-control-wrap\" data-name=\"barthel\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"barthel\" \/><\/span><\/label>\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es sociales<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>Barri\u00e8re linguistique\n<span class=\"wpcf7-form-control-wrap\" data-name=\"barrera-idiomatica\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"barrera-idiomatica\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Totale\">Totale<\/option><option value=\"Partielle\">Partielle<\/option><option value=\"Nulle\">Nulle<\/option><\/select><\/span><\/label>\n\n<label>Domicile:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"domicili\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"domicili\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Domicile fixe\">Domicile fixe<\/option><option value=\"Sans domicile fixe\">Sans domicile fixe<\/option><option value=\"Sans-abri\">Sans-abri<\/option><\/select><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Situation familiale:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"situacio-familiar\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"situacio-familiar\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Situation professionnelle:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"situacio-laboral\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"situacio-laboral\" \/><\/span><\/label>\n <\/div>\n<\/div>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Documentation<\/label>\n\n<label>Rapport m\u00e9dical*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-medic\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-medic\" \/><\/span><\/label>\n<label>DNI\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-dni\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-dni\" \/><\/span><\/label>\n<label>CIP\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-cip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-cip\" \/><\/span><\/label>\n<label>Rapport social\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-social\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-social\" \/><\/span><\/label>\n<label>Rapport infirmier\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-infermeria\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-infermeria\" \/><\/span><\/label>\n\n<button type='button' class='wpcf7-field-group-remove '>-<\/button><button type='button' class='wpcf7-field-group-add '>+<\/button><input type=\"hidden\" class=\"wpcf7-field-group-count\" name=\"_wpcf7_groups_count[pacients-TB]\" value=\"1\" \/><\/div><\/div>\n<\/div>\n\n\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:50px\">Donn\u00e9es du patient atteint d'ITL<\/label>\n\n<label>Y a-t-il des cas d'ITL? [Oui\/Non]\n<span class=\"wpcf7-form-control-wrap\" data-name=\"hi-ha-casos-itl\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"hi-ha-casos-itl\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Oui\">Oui<\/option><option value=\"Non\">Non<\/option><\/select><\/span>\n<\/label>\n<div data-id=\"conditional-group-casos-itl\" data-orig_data_id=\"conditional-group-casos-itl\" class=\"\" data-class=\"wpcf7cf_group\">\n<div data-wpcf7-group-id=\"pacients-ITL\" class=\"wpcf7-field-groups \"><div class=\"wpcf7-field-group\">\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>Nom et pr\u00e9nom*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom-pacient-ITL\"><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-pacient-ITL\" \/><\/span><\/label>\n\n<label>T\u00e9l\u00e9phone*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telefon-pacient-ITL\"><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=\"telefon-pacient-ITL\" \/><\/span><\/label>\n\n<label>Adresse*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-adreca-pacient-ITL\"><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=\"text-adreca-pacient-ITL\" \/><\/span>\n<\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Sexe*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Sexe-pacient-ITL\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Sexe-pacient-ITL\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Homme\">Homme<\/option><option value=\"Femme\">Femme<\/option><\/select><\/span><\/label>\n\n<label>Commune*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-municipi-pacient-ITL\"><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=\"text-municipi-pacient-ITL\" \/><\/span>\n<\/label>\n\n<label>Province*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-provincia-pacient-ITL\"><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=\"text-provincia-pacient-ITL\" \/><\/span>\n<\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>\u00c2ge*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"edat-pacient-ITL\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"edat-pacient-ITL\" \/><\/span><\/label>\n\n<label>Pays de naissance*:\n\t\t<span id=\"uacf7_country_select\" class=\"wpcf7-form-control-wrap pais-neixament-pacient-ITL\">\n\n\t\t\t<input id=\"uacf7_countries_pais-neixament-pacient-ITL\" type=\"text\" aria-required=\"true\" aria-invalid=\"false\" name=\"pais-neixament-pacient-ITL\" class=\"wpcf7-form-control wpcf7-uacf7_country_dropdown wpcf7-validates-as-required uacf7_country_dropdown_with_flag\">\n\n\t\t\t<span><\/span>\n\n\t\t\t<div style=\"display:none;\">\n\t\t\t\t<input type=\"hidden\" id=\"uacf7_countries_pais-neixament-pacient-ITL_code\" data-countrycodeinput=\"1\" readonly=\"readonly\" placeholder=\"Selected country code will appear here\" \/>\n\t\t\t<\/div>\n\n\t\t<\/span>\n\t\t<\/label>\n\n <\/div>\n<\/div>\n\n\n\n\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es m\u00e9dicales<\/label>\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>Cas index (Nom)*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-cas-index-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=\"text-cas-index-nom\" \/><\/span><\/label>\n\n<label>PPD* (choisir une)\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-PPD\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-PPD\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Positive\">Positive<\/option><option value=\"N\u00e9gative\">N\u00e9gative<\/option><option value=\"Non r\u00e9alis\u00e9e\">Non r\u00e9alis\u00e9e<\/option><\/select><\/span><\/label>\n\n<label>Sch\u00e9ma recommand\u00e9*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-pauta-recomanada\"><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=\"text-pauta-recomanada\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Lien de parent\u00e9 avec le cas index*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-parentiu-cas-index\"><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=\"text-parentiu-cas-index\" \/><\/span>\n<\/label>\n\n<label>Diam\u00e8tre (mm) de l'induration*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"number-diametre-induracio\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"number-diametre-induracio\" \/><\/span><\/label>\n\n<label>Date de d\u00e9but du traitement (commenc\u00e9 ou recommand\u00e9)*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-inici-tractament\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-inici-tractament\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Type de contact (choisir un)*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-tipus-contacte\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-tipus-contacte\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Familial\">Familial<\/option><option value=\"Scolaire\">Scolaire<\/option><option value=\"Entreprise\/Institution\">Entreprise\/Institution<\/option><option value=\"Espace de loisirs\">Espace de loisirs<\/option><\/select><\/span><\/label>\n\n<label>IGRA*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-IGRA\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-IGRA\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Positive\">Positive<\/option><option value=\"N\u00e9gative\">N\u00e9gative<\/option><option value=\"Non r\u00e9alis\u00e9e\">Non r\u00e9alis\u00e9e<\/option><\/select><\/span><\/label>\n\n<label>Dur\u00e9e de traitement recommand\u00e9e*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"number-tractament-recomanat\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"number-tractament-recomanat\" \/><\/span><\/label>\n <\/div>\n<\/div>\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:50px\">Informations suppl\u00e9mentaires.<\/label>\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:50px\">Donn\u00e9es du patient atteint d'ITL<\/label>\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>CIP:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cip-pacient-ITL\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cip-pacient-ITL\" \/><\/span><\/label>\n\n<label>Pays d'origine (Pays d'o\u00f9 le patient est r\u00e9cemment arriv\u00e9):\n\t\t<span id=\"uacf7_country_select\" class=\"wpcf7-form-control-wrap pais-origen-pacient-ITL\">\n\n\t\t\t<input id=\"uacf7_countries_pais-origen-pacient-ITL\" type=\"text\" aria-invalid=\"false\" name=\"pais-origen-pacient-ITL\" class=\"wpcf7-form-control wpcf7-uacf7_country_dropdown uacf7_country_dropdown_with_flag\">\n\n\t\t\t<span><\/span>\n\n\t\t\t<div style=\"display:none;\">\n\t\t\t\t<input type=\"hidden\" id=\"uacf7_countries_pais-origen-pacient-ITL_code\" data-countrycodeinput=\"1\" readonly=\"readonly\" placeholder=\"Selected country code will appear here\" \/>\n\t\t\t<\/div>\n\n\t\t<\/span>\n\t\t<\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Autres num\u00e9ros de t\u00e9l\u00e9phone:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"altres-telefons-pacient-ITL\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"altres-telefons-pacient-ITL\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Date d'arriv\u00e9e pour vivre en Espagne:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-arribada-espanya-pacient-ITL\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-arribada-espanya-pacient-ITL\" \/><\/span><\/label>\n <\/div>\n<\/div>\n\n\n\n\n\n\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es sociales<\/label>\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\">\n<label>Barri\u00e8re linguistique\n<span class=\"wpcf7-form-control-wrap\" data-name=\"barrera-idiomatica\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"barrera-idiomatica\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Totale\">Totale<\/option><option value=\"Partielle\">Partielle<\/option><option value=\"Nulle\">Nulle<\/option><\/select><\/span><\/label>\n\n<label>Domicile:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"domicili\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"domicili\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Domicile fixe\">Domicile fixe<\/option><option value=\"Sans domicile fixe\">Sans domicile fixe<\/option><option value=\"Sans-abri\">Sans-abri<\/option><\/select><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Situation familiale:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"situacio-familiar\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"situacio-familiar\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Situation professionnelle:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"situacio-laboral\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"situacio-laboral\" \/><\/span><\/label>\n <\/div>\n<\/div>\n\n\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Documentation<\/label>\n\n<label>Rapport m\u00e9dical\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-medic\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-medic\" \/><\/span><\/label>\n<label>DNI\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-dni\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file-dni\" \/><\/span><\/label>\n<label>CIP\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-cip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file-cip\" \/><\/span><\/label>\n<label>Rapport social\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-social\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" 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