{"id":6269,"date":"2024-09-13T14:59:06","date_gmt":"2024-09-13T12:59:06","guid":{"rendered":"https:\/\/www.serveisclinics.com\/effectuez-un-paiement-etoda-itl\/"},"modified":"2026-09-26T13:57:14","modified_gmt":"2026-09-26T11:57:14","slug":"effectuez-un-paiement-etoda-itl","status":"publish","type":"page","link":"https:\/\/www.serveisclinics.com\/fr\/effectuez-un-paiement-etoda-itl\/","title":{"rendered":"Demande d\u2019admission \u00e0 l\u2019ETODA \u2013 ITL"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6269\" class=\"elementor elementor-6269 elementor-2213\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7b33498 e-flex e-con-boxed e-con e-child\" data-id=\"7b33498\" 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-79663f1 elementor-widget elementor-widget-heading\" data-id=\"79663f1\" 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-88f3743 e-flex e-con-boxed e-con e-parent\" data-id=\"88f3743\" 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-9bea11e bold elementor-widget elementor-widget-heading\" data-id=\"9bea11e\" 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 Cas d\u2019infection tuberculeuse latente (ITL)<\/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-e709ae4 e-flex e-con-boxed e-con e-parent\" data-id=\"e709ae4\" 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-abfd345 elementor-widget elementor-widget-shortcode\" data-id=\"abfd345\" 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-f7008-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"7008\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/6269#wpcf7-f7008-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"7008\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f7008-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:7008,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;informacio-opcional&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mostrar-camps-opcionals&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;1&quot;}]},{&quot;then_field&quot;:&quot;group-cas-index&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;menu-cas-index&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Oui&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;,&quot;notice_dismissed_rollback-cf7-5.9.7&quot;:true}}\" \/><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-7008 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-7008 input[type=\"email\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"number\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"password\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"search\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"tel\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"text\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"url\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"date\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"radio\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 input[type=\"checkbox\"],\n\t\t\t\t\t.uacf7-uacf7style-7008 select,\n\t\t\t\t\t.uacf7-uacf7style-7008 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-7008 .wpcf7-radio span,\n\t\t\t\t\t.uacf7-uacf7style-7008 .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-7008 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-7008 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-7008 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-7008\"><div class=\"uacf7-form-wrapper-container uacf7-form-7008  uacf7-uacf7style uacf7-uacf7style-7008\"><label style=\"font-size: 20px;font-weight: 600\">Donn\u00e9es du demandeur<\/label>\n\n<div class=\"uacf7-row\">\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>\n <\/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\n <\/div>\n<\/div>\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es du patient<\/label>\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\"><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\" \/><\/span><\/label>\n\n<label>T\u00e9l\u00e9phone*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telefon-pacient\"><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\" \/><\/span><\/label>\n\n<label>Province*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"provicia-pacient\"><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=\"provicia-pacient\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Sexe*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Sexe-pacient\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Sexe-pacient\"><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 au moment de l'admission*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"direccio-momentIngres-pacient\"><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=\"direccio-momentIngres-pacient\" \/><\/span><\/label>\n\n<label>Pays de naissance*:\n\t\t<span id=\"uacf7_country_select\" class=\"wpcf7-form-control-wrap pais-neixament\">\n\n\t\t\t<input id=\"uacf7_countries_pais-neixament\" type=\"text\" aria-required=\"true\" aria-invalid=\"false\" name=\"pais-neixament\" 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_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>\u00c2ge*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"edat-pacient\"><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\" \/><\/span><\/label>\n\n\n<label>Commune*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"municipi-pacient\"><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=\"municipi-pacient\" \/><\/span><\/label>\n <\/div>\n\n<\/div>\n\n<label>Le cas index est-il connu?*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-cas-index\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-cas-index\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Oui\">Oui<\/option><option value=\"Non\">Non<\/option><\/select><\/span><\/label>\n\n<div data-id=\"group-cas-index\" data-orig_data_id=\"group-cas-index\" class=\"\" data-class=\"wpcf7cf_group\">\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Cas index<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>Cas index (Nom et lien de parent\u00e9)\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-cas-index-nom-parentiu\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-cas-index-nom-parentiu\" \/><\/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\" 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\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\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-pauta-recomanada\" \/><\/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\" 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\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-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"number-diametre-induracio\" \/><\/span><\/label>\n\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-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-inici-tractament\" \/><\/span><\/label>\n <\/div>\n\n<div class=\"uacf7-col-4\"> \n<label>Cohabitant:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-convivent\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"menu-convivent\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><option value=\"Oui\">Oui<\/option><option value=\"Non\">Non<\/option><\/select><\/span>\n<\/label>\n\n<label>IGRA\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-IGRA\"><select class=\"wpcf7-form-control wpcf7-select\" 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<\/div>\n\n<label>Commentaires\n<span class=\"wpcf7-form-control-wrap\" data-name=\"comentaris\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"comentaris\"><\/textarea><\/span><\/label>\n\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\n<div data-id=\"informacio-opcional\" data-orig_data_id=\"informacio-opcional\" class=\"\" data-class=\"wpcf7cf_group\">\n<label style=\"font-size: 20px;font-weight: 600\">Donn\u00e9es du demandeur<\/label>\n\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\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Donn\u00e9es du patient<\/label>\n<div class=\"uacf7-row\">\n\n<div class=\"uacf7-col-4\"> \n<label>CIP:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cip-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cip-pacient\" \/><\/span><\/label> \n\n<label>Date d'arriv\u00e9e pour vivre en Espagne:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-arribada-espanya-pacient\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-arribada-espanya-pacient\" \/><\/span><\/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\"><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\" \/><\/span><\/label>\n\n\n<\/div>\n\n<div class=\"uacf7-col-4\"> \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\">\n\n\t\t\t<input id=\"uacf7_countries_pais-origen-pacient\" type=\"text\" aria-invalid=\"false\" name=\"pais-origen-pacient\" 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_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<\/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\" 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\" 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\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-infermeria\" \/><\/span><\/label>\n\n\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/><\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\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\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Demande d\u2019admission Formulaire ETODA \u2013 Cas d\u2019infection tuberculeuse latente 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