Assit France Online<\/title>\r\n <link rel=\"stylesheet\" href=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/font-awesome\/6.0.0\/css\/all.min.css\">\r\n <style>\r\n * {\r\n margin: 0;\r\n padding: 0;\r\n box-sizing: border-box;\r\n }\r\n\r\n body {\r\n font-family: 'Inter', 'Segoe UI', system-ui, -apple-system, sans-serif;\r\n background: linear-gradient(145deg, #f0f4ff 0%, #e8effa 100%);\r\n overflow-x: hidden;\r\n color: #0a2540;\r\n }\r\n\r\n \/* Effets 3D globaux *\/\r\n .scene-3d {\r\n perspective: 1000px;\r\n }\r\n\r\n @keyframes float-soft {\r\n 0% { transform: translateY(0px) rotateX(0deg); }\r\n 50% { transform: translateY(-6px) rotateX(1deg); }\r\n 100% { transform: translateY(0px) rotateX(0deg); }\r\n }\r\n\r\n @keyframes glow-pulse {\r\n 0% { box-shadow: 0 20px 40px -12px rgba(0, 102, 204, 0.15); }\r\n 50% { box-shadow: 0 30px 55px -12px rgba(0, 102, 204, 0.3); }\r\n 100% { box-shadow: 0 20px 40px -12px rgba(0, 102, 204, 0.15); }\r\n }\r\n\r\n \/* Header verre 3D *\/\r\n .header-glass {\r\n position: sticky;\r\n top: 0;\r\n z-index: 100;\r\n background: rgba(255, 255, 255, 0.85);\r\n backdrop-filter: blur(16px);\r\n border-bottom: 1px solid rgba(255,255,255,0.6);\r\n box-shadow: 0 4px 20px rgba(0,0,0,0.02);\r\n }\r\n\r\n .logo-3d {\r\n font-size: 1.8rem;\r\n font-weight: 800;\r\n letter-spacing: -0.5px;\r\n }\r\n\r\n .logo-3d .blue {\r\n background: linear-gradient(135deg, #0066cc, #0f5cff);\r\n -webkit-background-clip: text;\r\n background-clip: text;\r\n color: transparent;\r\n }\r\n\r\n .logo-3d .green {\r\n background: linear-gradient(135deg, #00b67a, #009966);\r\n -webkit-background-clip: text;\r\n background-clip: text;\r\n color: transparent;\r\n }\r\n\r\n \/* Carte principale 3D *\/\r\n .card-3d {\r\n background: rgba(255, 255, 255, 0.97);\r\n backdrop-filter: blur(2px);\r\n border-radius: 48px;\r\n padding: 40px 32px;\r\n box-shadow: 0 35px 55px -20px rgba(0, 0, 0, 0.2), 0 0 0 1px rgba(255,255,255,0.8);\r\n transform: translateZ(15px) rotateX(1deg);\r\n transition: transform 0.35s ease, box-shadow 0.35s ease;\r\n animation: float-soft 5s infinite ease-in-out;\r\n }\r\n\r\n .card-3d:hover {\r\n transform: translateZ(25px) rotateX(0deg);\r\n box-shadow: 0 45px 70px -18px rgba(0, 0, 0, 0.25);\r\n }\r\n\r\n \/* Badges *\/\r\n .badge-modern {\r\n background: linear-gradient(115deg, #ffffff, #f5f9ff);\r\n border-radius: 60px;\r\n padding: 8px 20px;\r\n font-size: 0.8rem;\r\n font-weight: 600;\r\n color: #0066cc;\r\n display: inline-block;\r\n box-shadow: 0 4px 10px rgba(0,0,0,0.03), inset 0 1px 0 white;\r\n }\r\n\r\n \/* Statistiques flottantes *\/\r\n .stat-3d {\r\n background: rgba(255,255,255,0.9);\r\n backdrop-filter: blur(12px);\r\n border-radius: 32px;\r\n padding: 20px;\r\n text-align: center;\r\n transition: all 0.25s;\r\n border: 1px solid rgba(255,255,255,0.6);\r\n box-shadow: 0 15px 30px -12px rgba(0,0,0,0.08);\r\n }\r\n\r\n .stat-3d:hover {\r\n transform: translateY(-5px);\r\n background: white;\r\n }\r\n\r\n \/* \u00c9tapes 3D *\/\r\n .step-3d {\r\n background: white;\r\n border-radius: 36px;\r\n padding: 28px 20px;\r\n transition: all 0.3s cubic-bezier(0.2, 0.9, 0.4, 1.1);\r\n box-shadow: 0 20px 35px -12px rgba(0,0,0,0.1);\r\n }\r\n\r\n .step-3d:hover {\r\n transform: translateY(-8px) scale(1.02);\r\n box-shadow: 0 30px 45px -12px rgba(0,102,204,0.2);\r\n }\r\n\r\n .step-circle {\r\n width: 56px;\r\n height: 56px;\r\n background: linear-gradient(145deg, #0066cc, #0f5cff);\r\n border-radius: 30px;\r\n display: flex;\r\n align-items: center;\r\n justify-content: center;\r\n font-size: 1.8rem;\r\n font-weight: 800;\r\n color: white;\r\n margin-bottom: 20px;\r\n box-shadow: 0 12px 18px -6px rgba(0,102,204,0.4);\r\n }\r\n\r\n \/* Features 3D *\/\r\n .feature-3d {\r\n background: rgba(255,255,255,0.85);\r\n backdrop-filter: blur(8px);\r\n border-radius: 28px;\r\n padding: 20px 16px;\r\n text-align: center;\r\n transition: 0.2s;\r\n border: 1px solid rgba(255,255,255,0.7);\r\n }\r\n\r\n .feature-3d i {\r\n font-size: 2rem;\r\n color: #0066cc;\r\n margin-bottom: 12px;\r\n }\r\n\r\n \/* CTA final *\/\r\n .cta-glow {\r\n background: linear-gradient(135deg, #00b67a, #009966);\r\n border: none;\r\n padding: 16px 32px;\r\n border-radius: 60px;\r\n font-weight: 700;\r\n font-size: 1.1rem;\r\n color: white;\r\n display: inline-block;\r\n text-decoration: none;\r\n box-shadow: 0 15px 30px -8px rgba(0,182,122,0.4);\r\n transition: all 0.2s;\r\n }\r\n\r\n .cta-glow:active {\r\n transform: scale(0.97);\r\n }\r\n\r\n \/* Container *\/\r\n .container {\r\n max-width: 1200px;\r\n margin: 0 auto;\r\n padding: 0 24px;\r\n }\r\n\r\n \/* Zone du formulaire WPForms *\/\r\n .wpforms-integration {\r\n width: 100%;\r\n }\r\n\r\n \/* Aucun style intrusif pour le formulaire r\u00e9el *\/\r\n .wpforms-integration .wpforms-container {\r\n width: 100%;\r\n }\r\n\r\n \/* Responsive *\/\r\n @media (max-width: 768px) {\r\n .container {\r\n padding: 0 16px;\r\n }\r\n .card-3d {\r\n padding: 28px 20px;\r\n border-radius: 32px;\r\n }\r\n .step-circle {\r\n width: 48px;\r\n height: 48px;\r\n font-size: 1.5rem;\r\n }\r\n .logo-3d {\r\n font-size: 1.5rem;\r\n }\r\n }\r\n\r\n \/* D\u00e9cors flottants 3D *\/\r\n .orb {\r\n position: fixed;\r\n border-radius: 50%;\r\n filter: blur(70px);\r\n z-index: -1;\r\n pointer-events: none;\r\n }\r\n\r\n footer {\r\n text-align: center;\r\n padding: 40px 20px 30px;\r\n font-size: 0.75rem;\r\n color: #5a6e8a;\r\n }\r\n <\/style>\r\n \r\n<script>\r\n gtag('event', 'conversion', {\r\n 'send_to': 'AW-17946752989\/etzDCPuYr_cbEN3v1u1C',\r\n 'value': 1.0,\r\n 'currency': 'EUR'\r\n });\r\n<\/script>\r\n\r\n<\/head>\r\n<body>\r\n\r\n<div class=\"orb\" style=\"width: 350px; height: 350px; background: radial-gradient(circle, rgba(0,102,204,0.08), transparent); top: -120px; left: -80px;\"><\/div>\r\n<div class=\"orb\" style=\"width: 400px; height: 400px; background: radial-gradient(circle, rgba(0,182,122,0.06), transparent); bottom: -100px; right: -100px;\"><\/div>\r\n\r\n<header class=\"header-glass\">\r\n <div class=\"container\">\r\n <div style=\"display: flex; justify-content: space-between; align-items: center; padding: 16px 0;\">\r\n <div class=\"logo-3d\">\r\n <span class=\"blue\">AssistFrance<\/span><span class=\"green\">Online<\/span>\r\n <\/div>\r\n <div style=\"font-size: 0.85rem; background: rgba(0,102,204,0.1); padding: 6px 14px; border-radius: 40px;\">\r\n <i class=\"fas fa-shield-alt\"><\/i> T\u00c9L\u00c9CONSULTATION SANS RENDEZ-VOUS \u2013 7J\/7\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n<\/header>\r\n\r\n<main class=\"scene-3d\" style=\"padding: 45px 0 60px;\">\r\n <div class=\"container\">\r\n \r\n <div class=\"card-3d\" style=\"margin-bottom: 50px;\">\r\n <div style=\"text-align: center; margin-bottom: 30px;\">\r\n <span class=\"badge-modern\"><i class=\"fas fa-stethoscope\"><\/i> Obtenez votre arr\u00eat maladie en ligne. Rapide, simple et s\u00e9curis\u00e9.<\/span>\r\n <h1 style=\"font-size: 2rem; margin-top: 24px; font-weight: 800; background: linear-gradient(125deg, #0a2540, #0066cc); -webkit-background-clip: text; background-clip: text; color: transparent;\">Commander votre arr\u00eat maladie<br>en 5 minutes<\/h1>\r\n <p style=\"color: #456e93; margin-top: 12px; font-size: 1rem;\">Remplissez le court formulaire maintenant, recevez votre arr\u00eat<\/p>\r\n <\/div>\r\n\r\n \r\n <div class=\"wpforms-integration\">\r\n \r\n <div id=\"wpforms-shortcode-container\">\r\n \r\n <style id=\"wpforms-css-vars-44\">\n\t\t\t\t#wpforms-44 {\n\t\t\t\t--wpforms-field-border-radius: 22px;\n--wpforms-field-border-color: #073eff;\n--wpforms-field-border-color-spare: #073eff;\n--wpforms-field-text-color: #666666;\n--wpforms-label-color: #666666;\n--wpforms-label-sublabel-color: #666666;\n--wpforms-label-error-color: #da0000;\n--wpforms-button-border-radius: 100px;\n--wpforms-button-background-color: #073eff;\n--wpforms-button-border-color: #073eff;\n--wpforms-container-padding: 60px;\n--wpforms-container-border-style: solid;\n--wpforms-container-border-radius: 50px;\n--wpforms-container-border-color: #f3f3f3;\n--wpforms-background-color: #ffffff;\n--wpforms-page-break-color: #073eff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: 0px 30px 50px -10px rgba(0, 0, 0, 0.15);\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-stripe wpforms-render-modern\" id=\"wpforms-44\"><form id=\"wpforms-form-44\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"44\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/9\" data-token=\"a97a3eed3bc757defd455fd246c35b98\" data-token-time=\"1780673287\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/div><div class=\"wpforms-page-indicator circles\" data-indicator=\"circles\" data-indicator-color=\"#3b48b8\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"4\" tabindex=\"-1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#3b48b8\">1<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-2\"><span class=\"wpforms-page-indicator-page-number\">2<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-3\"><span class=\"wpforms-page-indicator-page-number\">3<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-4\"><span class=\"wpforms-page-indicator-page-number\">4<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-44-field_4-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"4\"><\/div><div id=\"wpforms-44-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_14\">\ud83e\udda0 Quelle maladie vous concerne ? *<\/label><select id=\"wpforms-44-field_14\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][14]\"><option value=\"\" class=\"placeholder\" disabled selected='selected'><\/option><option value=\"Veuillez s\u00e9lectionner\" class=\"choice-1 depth-1\" >Veuillez s\u00e9lectionner<\/option><option value=\"Gastro-ent\u00e9rite\" class=\"choice-2 depth-1\" >Gastro-ent\u00e9rite<\/option><option value=\"Sympt\u00f4me Corona\" class=\"choice-3 depth-1\" >Sympt\u00f4me Corona<\/option><option value=\"Stress\" class=\"choice-7 depth-1\" >Stress<\/option><option value=\"Migraine\" class=\"choice-6 depth-1\" >Migraine<\/option><option value=\"Mal de dos\" class=\"choice-5 depth-1\" >Mal de dos<\/option><option value=\"Douleurs menstruelles\" class=\"choice-4 depth-1\" >Douleurs menstruelles<\/option><option value=\"Cystite\" class=\"choice-8 depth-1\" >Cystite<\/option><option value=\"Blessures\" class=\"choice-9 depth-1\" >Blessures<\/option><option value=\"Douleurs abdominales \/ pelviennes\" class=\"choice-10 depth-1\" >Douleurs abdominales \/ pelviennes<\/option><option value=\"Hypertension\" class=\"choice-11 depth-1\" >Hypertension<\/option><option value=\"Allergie\" class=\"choice-12 depth-1\" >Allergie<\/option><option value=\"Probl\u00e8mes dentaires\" class=\"choice-15 depth-1\" >Probl\u00e8mes dentaires<\/option><option value=\"Maux de t\u00eate\" class=\"choice-14 depth-1\" >Maux de t\u00eate<\/option><option value=\"Naus\u00e9es\/ Vomissements\" class=\"choice-16 depth-1\" >Naus\u00e9es\/ Vomissements<\/option><option value=\"Gastrite\" class=\"choice-17 depth-1\" >Gastrite<\/option><option value=\"Probl\u00e8mes articulaires\" class=\"choice-18 depth-1\" >Probl\u00e8mes articulaires<\/option><option value=\"Syndrome d\u2019\u00e9puisement\" class=\"choice-20 depth-1\" >Syndrome d\u2019\u00e9puisement<\/option><\/select><div id=\"wpforms-44-field_14-description\" class=\"wpforms-field-description\">Une seule possibilit\u00e9<\/div><\/div><div id=\"wpforms-44-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 ? *<\/legend><ul id=\"wpforms-44-field_16\" class=\"wpforms-icon-choices wpforms-icon-choices-default wpforms-icon-choices-small\" data-choice-limit=\"1\" style=\"--wpforms-icon-choices-color: #066aab;\"><li class=\"choice-1 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_1\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM369 209c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-111 111-47-47c-9.4-9.4-24.6-9.4-33.9 0s-9.4 24.6 0 33.9l64 64c9.4 9.4 24.6 9.4 33.9 0L369 209z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_1\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_16_1-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Oui<\/span>\n\t\t\t<\/label><\/li><li class=\"choice-2 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_2\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM175 175c-9.4 9.4-9.4 24.6 0 33.9l47 47-47 47c-9.4 9.4-9.4 24.6 0 33.9s24.6 9.4 33.9 0l47-47 47 47c9.4 9.4 24.6 9.4 33.9 0s9.4-24.6 0-33.9l-47-47 47-47c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-47 47-47-47c-9.4-9.4-24.6-9.4-33.9 0z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_2\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_16_2-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Non<\/span>\n\t\t\t<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\"> S\u00e9lectionnez vos sympt\u00f4mes : *<\/legend><ul id=\"wpforms-44-field_17\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fi\u00e8vre\" aria-errormessage=\"wpforms-44-field_17_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_1\">Fi\u00e8vre<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Naus\u00e9es\" aria-errormessage=\"wpforms-44-field_17_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_2\">Naus\u00e9es<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Diarrh\u00e9e\" aria-errormessage=\"wpforms-44-field_17_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_3\">Diarrh\u00e9e<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux sans mucus\" aria-errormessage=\"wpforms-44-field_17_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_4\">Toux sans mucus<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux avec mucosit\u00e9s\" aria-errormessage=\"wpforms-44-field_17_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_5\">Toux avec mucosit\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Malaise\" aria-errormessage=\"wpforms-44-field_17_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_6\">Malaise<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fatigue\" aria-errormessage=\"wpforms-44-field_17_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_7\">Fatigue<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_9\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Hypertension art\u00e9rielle\" aria-errormessage=\"wpforms-44-field_17_9-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_9\">Hypertension art\u00e9rielle<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_10\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Stress\" aria-errormessage=\"wpforms-44-field_17_10-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_10\">Stress<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_11\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Troubles du sommeil\" aria-errormessage=\"wpforms-44-field_17_11-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_11\">Troubles du sommeil<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd12 Sympt\u00f4mes principaux *<\/legend><ul id=\"wpforms-44-field_24\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"T\u00eate\" aria-errormessage=\"wpforms-44-field_24_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_1\">T\u00eate<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Ventre\" aria-errormessage=\"wpforms-44-field_24_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_2\">Ventre<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dent\" aria-errormessage=\"wpforms-44-field_24_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_3\">Dent<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dos\" aria-errormessage=\"wpforms-44-field_24_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_4\">Dos<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Cou\" aria-errormessage=\"wpforms-44-field_24_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_7\">Cou<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Membres\" aria-errormessage=\"wpforms-44-field_24_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_6\">Membres<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Oreille\" aria-errormessage=\"wpforms-44-field_24_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_5\">Oreille<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Organe sexuel\" aria-errormessage=\"wpforms-44-field_24_8-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_8\">Organe sexuel<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udde0 Intensit\u00e9 de la douleur *<\/legend><ul id=\"wpforms-44-field_27\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_27_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_27_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_2\">Non<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Peut-\u00eatre\" aria-errormessage=\"wpforms-44-field_27_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_3\">Peut-\u00eatre<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_30\">\ud83d\udc8a M\u00e9dicaments d\u00e9j\u00e0 pris ?<\/label><textarea id=\"wpforms-44-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-44-field_30-error\" ><\/textarea><\/div><div id=\"wpforms-44-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\">\u26a0\ufe0f Pr\u00e9sentez-vous un facteur de risque ?<\/legend><ul id=\"wpforms-44-field_31\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_31_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_31_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd14 Votre employeur est-il insatisfait de votre travail ?<\/legend><ul id=\"wpforms-44-field_35\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_35_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_35_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-44-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">\ud83c\udd95 Type de demande <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_37\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-44-field_37_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Initial\" aria-errormessage=\"wpforms-44-field_37_1-error\" required checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_1\">Initial<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_37_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Prolongation\" aria-errormessage=\"wpforms-44-field_37_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_2\">Prolongation<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_41\">\ud83d\udc54 Votre profession * <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-44-field_41\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-44-field_41-error\" required><\/textarea><\/div><div id=\"wpforms-44-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">\u00c0 quel point votre travail est-il physiquement exigeant ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_46\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"L\u00e9ger\" aria-errormessage=\"wpforms-44-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_1\">L\u00e9ger<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Moyen\" aria-errormessage=\"wpforms-44-field_46_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_2\">Moyen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Elev\u00e9\" aria-errormessage=\"wpforms-44-field_46_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_3\">Elev\u00e9<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_48-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"48\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udcc5 Dates souhait\u00e9es\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_49-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_49\">D\u00e9but: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_49\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][49][date]\" aria-errormessage=\"wpforms-44-field_49-error\" aria-describedby=\"wpforms-44-field_49-description\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-44-field_49-description\" class=\"wpforms-field-description\">\u201cVeuillez s\u00e9lectionner une date comprise entre aujourd\u2019hui et les 5 derniers jours.\"<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_50-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_50\">Fin: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_50\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][50][date]\" aria-errormessage=\"wpforms-44-field_50-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_52-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"52\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udc64 Identit\u00e9\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_53-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][53][first]\" placeholder=\"Votre Pr\u00e9nom\" aria-errormessage=\"wpforms-44-field_53-error\" required><label for=\"wpforms-44-field_53\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][53][last]\" placeholder=\"Votre Nom\" aria-errormessage=\"wpforms-44-field_53-last-error\" required><label for=\"wpforms-44-field_53-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_56-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_56\">\ud83d\udcf1T\u00e9l\u00e9phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-44-field_56\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][56]\" aria-label=\"\ud83d\udcf1T\u00e9l\u00e9phone \" aria-errormessage=\"wpforms-44-field_56-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_55-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_55\">\ud83c\udf82 Date de naissance : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_55\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][55][date]\" aria-errormessage=\"wpforms-44-field_55-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_78-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_78\">\ud83d\udce9 E-mail <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-44-field_78\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][78]\" spellcheck=\"false\" aria-errormessage=\"wpforms-44-field_78-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_40-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"40\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-44-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"51\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83c\udfe0 Adresse postale\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_61-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label\">Adresse: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-44-field_61\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][61][address1]\" aria-errormessage=\"wpforms-44-field_61-error\" required><label for=\"wpforms-44-field_61\" class=\"wpforms-field-sublabel after\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][61][city]\" aria-errormessage=\"wpforms-44-field_61-city-error\" required><label for=\"wpforms-44-field_61-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_61-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][61][state]\" aria-errormessage=\"wpforms-44-field_61-state-error\" required><label for=\"wpforms-44-field_61-state\" class=\"wpforms-field-sublabel after\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][61][postal]\" aria-errormessage=\"wpforms-44-field_61-postal-error\" required><label for=\"wpforms-44-field_61-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_82-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_82\">Pays <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-44-field_82\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][82]\" placeholder=\"France\" aria-errormessage=\"wpforms-44-field_82-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_70-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_70\">\ud83e\udeaa ID S\u00e9curit\u00e9 Sociale <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-44-field_70\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][70]\" step=\"any\" aria-errormessage=\"wpforms-44-field_70-error\" aria-describedby=\"wpforms-44-field_70-description\" required><div id=\"wpforms-44-field_70-description\" class=\"wpforms-field-description\">\u2022 Nous utilisons votre num\u00e9ro de S\u00e9curit\u00e9 sociale uniquement pour l'inscrire sur l'arr\u00eat de travail.<\/div><\/div><div id=\"wpforms-44-field_36-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"36\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4 last \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-44-field_108-container\" class=\"wpforms-field wpforms-field-payment-single\" data-field-id=\"108\"><label class=\"wpforms-field-label\">Prix <\/label><div class=\"wpforms-single-item-price-content\"><div class=\"wpforms-single-item-price wpforms-field-medium wpforms-payment-price\"> <span class=\"wpforms-price\">23,00 €<\/span><\/div><\/div><input type=\"hidden\" id=\"wpforms-44-field_108\" class=\"wpforms-field-medium wpforms-payment-price\" name=\"wpforms[fields][108]\" value=\"23,00 €\"><\/div><div id=\"wpforms-44-field_111-container\" class=\"wpforms-field wpforms-field-stripe-credit-card\" data-field-id=\"111\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">formulation neutre, administrative <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-no-columns wpforms-field-medium \" data-sublabel-position=\"above\" data-link-email=\"78\" data-required=\"1\"><div id=\"wpforms-field-stripe-payment-element-44\"><\/div><input type=\"text\" class=\"wpforms-stripe-credit-card-hidden-input\" name=\"wpforms[stripe-credit-card-hidden-input-44]\" disabled style=\"display: none;\"><\/div><div id=\"wpforms-44-field_111-description\" class=\"wpforms-field-description\">Service administratif \u2013 transmission de dossier au professionnel partenaire\n<\/div><\/div><div id=\"wpforms-44-field_5-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"5\"><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"44\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-44\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Terminer\" aria-live=\"assertive\" value=\"wpforms-submit\">Terminer<\/button><img decoding=\"async\" src=\"https:\/\/app.assistfranceonline.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Chargement en cours\"><\/div><\/form><\/div> \r\n <\/div>\r\n \r\n <div style=\"text-align: center; margin-top: 12px; font-size: 11px; color: #7c8ea0;\">\r\n <i class=\"fas fa-lock\"><\/i> Votre paiement est s\u00e9curis\u00e9 par Viva Payments.\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div style=\"display: grid; grid-template-columns: repeat(auto-fit, minmax(180px, 1fr)); gap: 24px; margin-bottom: 60px;\">\r\n <div class=\"stat-3d\"><i class=\"fas fa-file-medical\" style=\"font-size: 2rem; color:#0066cc;\"><\/i><h2 style=\"font-size: 2rem; margin: 8px 0 0;\">+25k<\/h2><p>Arr\u00eats d\u00e9livr\u00e9s<\/p><\/div>\r\n <div class=\"stat-3d\"><i class=\"fas fa-hourglass-half\" style=\"font-size: 2rem; color:#0066cc;\"><\/i><h2 style=\"font-size: 2rem; margin: 8px 0 0;\">5 min<\/h2><p>R\u00e9ponse <\/p><\/div>\r\n <div class=\"stat-3d\"><i class=\"fas fa-star\" style=\"font-size: 2rem; color:#0066cc;\"><\/i><h2 style=\"font-size: 2rem; margin: 8px 0 0;\">98%<\/h2><p>Satisfaction<\/p><\/div>\r\n <\/div>\r\n\r\n \r\n <h2 style=\"text-align: center; font-size: 1.9rem; margin-bottom: 40px;\">\u2728 Comment \u00e7a marche ? \u2728<\/h2>\r\n <div style=\"display: flex; flex-wrap: wrap; gap: 30px; justify-content: center; margin-bottom: 70px;\">\r\n <div class=\"step-3d\" style=\"flex: 1; min-width: 220px;\">\r\n <div class=\"step-circle\">1<\/div>\r\n <i class=\"fas fa-edit\" style=\"font-size: 2rem; color:#0066cc; margin-bottom: 12px; display: block;\"><\/i>\r\n <h3>Questionnaire simple<\/h3>\r\n <p style=\"color:#5a6e8a;\">R\u00e9pondez en quelques minutes sur votre \u00e9tat<\/p>\r\n <\/div>\r\n <div class=\"step-3d\" style=\"flex: 1; min-width: 220px;\">\r\n <div class=\"step-circle\">2<\/div>\r\n <i class=\"fas fa-user-md\" style=\"font-size: 2rem; color:#0066cc; margin-bottom: 12px; display: block;\"><\/i>\r\n <h3>Recevez votre PDF<\/h3>\r\n <p style=\"color:#5a6e8a;\">Votre arr\u00eat maladie pr\u00e9-rempli sera envoy\u00e9 par e-mail,<\/p>\r\n <\/div>\r\n <div class=\"step-3d\" style=\"flex: 1; min-width: 220px;\">\r\n <div class=\"step-circle\">3<\/div>\r\n <i class=\"fas fa-file-pdf\" style=\"font-size: 2rem; color:#0066cc; margin-bottom: 12px; display: block;\"><\/i>\r\n <h3>PDF imm\u00e9diat<\/h3>\r\n <p style=\"color:#5a6e8a;\">Recevez votre certificat par email<\/p>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div style=\"background: linear-gradient(120deg, rgba(255,255,255,0.5), rgba(240,248,255,0.6)); border-radius: 55px; padding: 35px 25px; margin-bottom: 50px;\">\r\n <h2 style=\"text-align: center; margin-bottom: 32px;\">Pourquoi <strong style=\"color:#0066cc;\">nous choisir<\/strong> ?<\/h2>\r\n <div style=\"display: grid; grid-template-columns: repeat(auto-fit, minmax(150px, 1fr)); gap: 20px;\">\r\n <div class=\"feature-3d\"><i class=\"fas fa-bolt\"><\/i><h4>Rapide<\/h4><small>Sans d\u00e9placement<\/small><\/div>\r\n <div class=\"feature-3d\"><i class=\"fas fa-shield-alt\"><\/i><h4>S\u00e9curis\u00e9<\/h4><small>Donn\u00e9es confidentielles<\/small><\/div>\r\n \r\n <div class=\"feature-3d\"><i class=\"fas fa-clock\"><\/i><h4>24\/7<\/h4><small>Service disponible<\/small><\/div>\r\n <div class=\"feature-3d\"><i class=\"fas fa-building\"><\/i><h4>Accept\u00e9 partout<\/h4><small>Validit\u00e9 employeur<\/small><\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"card-3d\" style=\"background: white; text-align: center; animation: glow-pulse 3s infinite;\">\r\n <i class=\"fas fa-quote-left\" style=\"font-size: 2rem; color: #00b67a; opacity: 0.6;\"><\/i>\r\n <p style=\"font-size: 1.1rem; max-width: 500px; margin: 16px auto; font-style: italic;\">\"Arr\u00eat re\u00e7u rapidement, site clair et fiable. Je recommande !\"<\/p>\r\n <p><strong>\u2014 Sophie M.<\/strong> \u2b50\u2b50\u2b50\u2b50\u2b50<\/p>\r\n <div style=\"margin: 28px 0 10px;\">\r\n <a href=\"#\" class=\"cta-glow\"><i class=\"fas fa-arrow-right\"><\/i> Obtenir mon arr\u00eat maintenant<\/a>\r\n <\/div>\r\n <p style=\"font-size: 0.7rem; margin-top: 16px;\">\ud83e\ude7a Arr\u00eat maladie officiel \u00b723\u20ac seulement<\/p>\r\n <\/div>\r\n\r\n \r\n <div style=\"margin-top: 45px; background: rgba(255,255,245,0.7); border-radius: 40px; padding: 28px;\">\r\n <h3><i class=\"fas fa-question-circle\"><\/i> Questions fr\u00e9quentes<\/h3>\r\n <details style=\"margin-top: 15px; background: white; border-radius: 50px; padding: 12px 20px;\"><summary style=\"font-weight: 600;\">L'arr\u00eat maladie en ligne est-il l\u00e9gal ?<\/summary><p style=\"margin-top: 8px;\">Oui, 100% conforme. R\u00e9alis\u00e9 par des m\u00e9decins inscrits \u00e0 l'Ordre.<\/p><\/details>\r\n <details style=\"margin-top: 12px; background: white; border-radius: 50px; padding: 12px 20px;\"><summary style=\"font-weight: 600;\">Quel est le d\u00e9lai d'obtention ?<\/summary><p style=\"margin-top: 8px;\">Sous 24h maximum, souvent en quelques heures.<\/p><\/details>\r\n <\/div>\r\n <\/div>\r\n<\/main>\r\n\r\n<footer>\r\n <p><i class=\"fas fa-heart\" style=\"color:#0066cc;\"><\/i> Assistfranceonline\u00a9 2026 \u2014 Service \r\nArr\u00eat de Travail En Ligne<\/p>\r\n \r\n<\/footer>\r\n\r\n<script>\r\n \/\/ V\u00e9rification simple : si le shortcode est remplac\u00e9 par WordPress, tout fonctionne.\r\n \/\/ Aucune alt\u00e9ration du formulaire natif WPForms.\r\n console.log(\"\u2705 Design 3D actif - Emplacement r\u00e9serv\u00e9 pour \");\r\n \/\/ Rappel silencieux dans la console\r\n const container = document.getElementById('wpforms-shortcode-container');\r\n if(container && container.innerText.includes('<style id=\"wpforms-css-vars-44\">\n\t\t\t\t#wpforms-44 {\n\t\t\t\t--wpforms-field-border-radius: 22px;\n--wpforms-field-border-color: #073eff;\n--wpforms-field-border-color-spare: #073eff;\n--wpforms-field-text-color: #666666;\n--wpforms-label-color: #666666;\n--wpforms-label-sublabel-color: #666666;\n--wpforms-label-error-color: #da0000;\n--wpforms-button-border-radius: 100px;\n--wpforms-button-background-color: #073eff;\n--wpforms-button-border-color: #073eff;\n--wpforms-container-padding: 60px;\n--wpforms-container-border-style: solid;\n--wpforms-container-border-radius: 50px;\n--wpforms-container-border-color: #f3f3f3;\n--wpforms-background-color: #ffffff;\n--wpforms-page-break-color: #073eff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: 0px 30px 50px -10px rgba(0, 0, 0, 0.15);\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-stripe wpforms-render-modern\" id=\"wpforms-44\"><form id=\"wpforms-form-44\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"44\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/9\" data-token=\"a97a3eed3bc757defd455fd246c35b98\" data-token-time=\"1780673287\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/div><div class=\"wpforms-page-indicator circles\" data-indicator=\"circles\" data-indicator-color=\"#3b48b8\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"4\" tabindex=\"-1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#3b48b8\">1<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-2\"><span class=\"wpforms-page-indicator-page-number\">2<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-3\"><span class=\"wpforms-page-indicator-page-number\">3<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-4\"><span class=\"wpforms-page-indicator-page-number\">4<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-44-field_4-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"4\"><\/div><div id=\"wpforms-44-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_14\">\ud83e\udda0 Quelle maladie vous concerne ? *<\/label><select id=\"wpforms-44-field_14\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][14]\"><option value=\"\" class=\"placeholder\" disabled selected='selected'><\/option><option value=\"Veuillez s\u00e9lectionner\" class=\"choice-1 depth-1\" >Veuillez s\u00e9lectionner<\/option><option value=\"Gastro-ent\u00e9rite\" class=\"choice-2 depth-1\" >Gastro-ent\u00e9rite<\/option><option value=\"Sympt\u00f4me Corona\" class=\"choice-3 depth-1\" >Sympt\u00f4me Corona<\/option><option value=\"Stress\" class=\"choice-7 depth-1\" >Stress<\/option><option value=\"Migraine\" class=\"choice-6 depth-1\" >Migraine<\/option><option value=\"Mal de dos\" class=\"choice-5 depth-1\" >Mal de dos<\/option><option value=\"Douleurs menstruelles\" class=\"choice-4 depth-1\" >Douleurs menstruelles<\/option><option value=\"Cystite\" class=\"choice-8 depth-1\" >Cystite<\/option><option value=\"Blessures\" class=\"choice-9 depth-1\" >Blessures<\/option><option value=\"Douleurs abdominales \/ pelviennes\" class=\"choice-10 depth-1\" >Douleurs abdominales \/ pelviennes<\/option><option value=\"Hypertension\" class=\"choice-11 depth-1\" >Hypertension<\/option><option value=\"Allergie\" class=\"choice-12 depth-1\" >Allergie<\/option><option value=\"Probl\u00e8mes dentaires\" class=\"choice-15 depth-1\" >Probl\u00e8mes dentaires<\/option><option value=\"Maux de t\u00eate\" class=\"choice-14 depth-1\" >Maux de t\u00eate<\/option><option value=\"Naus\u00e9es\/ Vomissements\" class=\"choice-16 depth-1\" >Naus\u00e9es\/ Vomissements<\/option><option value=\"Gastrite\" class=\"choice-17 depth-1\" >Gastrite<\/option><option value=\"Probl\u00e8mes articulaires\" class=\"choice-18 depth-1\" >Probl\u00e8mes articulaires<\/option><option value=\"Syndrome d\u2019\u00e9puisement\" class=\"choice-20 depth-1\" >Syndrome d\u2019\u00e9puisement<\/option><\/select><div id=\"wpforms-44-field_14-description\" class=\"wpforms-field-description\">Une seule possibilit\u00e9<\/div><\/div><div id=\"wpforms-44-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 ? *<\/legend><ul id=\"wpforms-44-field_16\" class=\"wpforms-icon-choices wpforms-icon-choices-default wpforms-icon-choices-small\" data-choice-limit=\"1\" style=\"--wpforms-icon-choices-color: #066aab;\"><li class=\"choice-1 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_1\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM369 209c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-111 111-47-47c-9.4-9.4-24.6-9.4-33.9 0s-9.4 24.6 0 33.9l64 64c9.4 9.4 24.6 9.4 33.9 0L369 209z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_1\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_16_1-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Oui<\/span>\n\t\t\t<\/label><\/li><li class=\"choice-2 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_2\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM175 175c-9.4 9.4-9.4 24.6 0 33.9l47 47-47 47c-9.4 9.4-9.4 24.6 0 33.9s24.6 9.4 33.9 0l47-47 47 47c9.4 9.4 24.6 9.4 33.9 0s9.4-24.6 0-33.9l-47-47 47-47c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-47 47-47-47c-9.4-9.4-24.6-9.4-33.9 0z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_2\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_16_2-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Non<\/span>\n\t\t\t<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\"> S\u00e9lectionnez vos sympt\u00f4mes : *<\/legend><ul id=\"wpforms-44-field_17\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fi\u00e8vre\" aria-errormessage=\"wpforms-44-field_17_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_1\">Fi\u00e8vre<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Naus\u00e9es\" aria-errormessage=\"wpforms-44-field_17_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_2\">Naus\u00e9es<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Diarrh\u00e9e\" aria-errormessage=\"wpforms-44-field_17_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_3\">Diarrh\u00e9e<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux sans mucus\" aria-errormessage=\"wpforms-44-field_17_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_4\">Toux sans mucus<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux avec mucosit\u00e9s\" aria-errormessage=\"wpforms-44-field_17_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_5\">Toux avec mucosit\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Malaise\" aria-errormessage=\"wpforms-44-field_17_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_6\">Malaise<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fatigue\" aria-errormessage=\"wpforms-44-field_17_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_7\">Fatigue<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_9\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Hypertension art\u00e9rielle\" aria-errormessage=\"wpforms-44-field_17_9-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_9\">Hypertension art\u00e9rielle<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_10\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Stress\" aria-errormessage=\"wpforms-44-field_17_10-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_10\">Stress<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_11\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Troubles du sommeil\" aria-errormessage=\"wpforms-44-field_17_11-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_11\">Troubles du sommeil<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd12 Sympt\u00f4mes principaux *<\/legend><ul id=\"wpforms-44-field_24\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"T\u00eate\" aria-errormessage=\"wpforms-44-field_24_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_1\">T\u00eate<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Ventre\" aria-errormessage=\"wpforms-44-field_24_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_2\">Ventre<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dent\" aria-errormessage=\"wpforms-44-field_24_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_3\">Dent<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dos\" aria-errormessage=\"wpforms-44-field_24_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_4\">Dos<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Cou\" aria-errormessage=\"wpforms-44-field_24_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_7\">Cou<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Membres\" aria-errormessage=\"wpforms-44-field_24_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_6\">Membres<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Oreille\" aria-errormessage=\"wpforms-44-field_24_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_5\">Oreille<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Organe sexuel\" aria-errormessage=\"wpforms-44-field_24_8-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_8\">Organe sexuel<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udde0 Intensit\u00e9 de la douleur *<\/legend><ul id=\"wpforms-44-field_27\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_27_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_27_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_2\">Non<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Peut-\u00eatre\" aria-errormessage=\"wpforms-44-field_27_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_3\">Peut-\u00eatre<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_30\">\ud83d\udc8a M\u00e9dicaments d\u00e9j\u00e0 pris ?<\/label><textarea id=\"wpforms-44-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-44-field_30-error\" ><\/textarea><\/div><div id=\"wpforms-44-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\">\u26a0\ufe0f Pr\u00e9sentez-vous un facteur de risque ?<\/legend><ul id=\"wpforms-44-field_31\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_31_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_31_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd14 Votre employeur est-il insatisfait de votre travail ?<\/legend><ul id=\"wpforms-44-field_35\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_35_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_35_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-44-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">\ud83c\udd95 Type de demande <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_37\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-44-field_37_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Initial\" aria-errormessage=\"wpforms-44-field_37_1-error\" required checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_1\">Initial<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_37_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Prolongation\" aria-errormessage=\"wpforms-44-field_37_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_2\">Prolongation<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_41\">\ud83d\udc54 Votre profession * <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-44-field_41\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-44-field_41-error\" required><\/textarea><\/div><div id=\"wpforms-44-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">\u00c0 quel point votre travail est-il physiquement exigeant ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_46\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"L\u00e9ger\" aria-errormessage=\"wpforms-44-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_1\">L\u00e9ger<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Moyen\" aria-errormessage=\"wpforms-44-field_46_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_2\">Moyen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Elev\u00e9\" aria-errormessage=\"wpforms-44-field_46_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_3\">Elev\u00e9<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_48-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"48\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udcc5 Dates souhait\u00e9es\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_49-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_49\">D\u00e9but: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_49\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][49][date]\" aria-errormessage=\"wpforms-44-field_49-error\" aria-describedby=\"wpforms-44-field_49-description\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-44-field_49-description\" class=\"wpforms-field-description\">\u201cVeuillez s\u00e9lectionner une date comprise entre aujourd\u2019hui et les 5 derniers jours.\"<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_50-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_50\">Fin: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_50\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][50][date]\" aria-errormessage=\"wpforms-44-field_50-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_52-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"52\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udc64 Identit\u00e9\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_53-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][53][first]\" placeholder=\"Votre Pr\u00e9nom\" aria-errormessage=\"wpforms-44-field_53-error\" required><label for=\"wpforms-44-field_53\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][53][last]\" placeholder=\"Votre Nom\" aria-errormessage=\"wpforms-44-field_53-last-error\" required><label for=\"wpforms-44-field_53-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_56-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_56\">\ud83d\udcf1T\u00e9l\u00e9phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-44-field_56\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][56]\" aria-label=\"\ud83d\udcf1T\u00e9l\u00e9phone \" aria-errormessage=\"wpforms-44-field_56-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_55-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_55\">\ud83c\udf82 Date de naissance : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_55\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][55][date]\" aria-errormessage=\"wpforms-44-field_55-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_78-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_78\">\ud83d\udce9 E-mail <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-44-field_78\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][78]\" spellcheck=\"false\" aria-errormessage=\"wpforms-44-field_78-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_40-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"40\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-44-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"51\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83c\udfe0 Adresse postale\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_61-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label\">Adresse: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-44-field_61\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][61][address1]\" aria-errormessage=\"wpforms-44-field_61-error\" required><label for=\"wpforms-44-field_61\" class=\"wpforms-field-sublabel after\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][61][city]\" aria-errormessage=\"wpforms-44-field_61-city-error\" required><label for=\"wpforms-44-field_61-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_61-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][61][state]\" aria-errormessage=\"wpforms-44-field_61-state-error\" required><label for=\"wpforms-44-field_61-state\" class=\"wpforms-field-sublabel after\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][61][postal]\" aria-errormessage=\"wpforms-44-field_61-postal-error\" required><label for=\"wpforms-44-field_61-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_82-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_82\">Pays <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-44-field_82\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][82]\" placeholder=\"France\" aria-errormessage=\"wpforms-44-field_82-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_70-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_70\">\ud83e\udeaa ID S\u00e9curit\u00e9 Sociale <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-44-field_70\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][70]\" step=\"any\" aria-errormessage=\"wpforms-44-field_70-error\" aria-describedby=\"wpforms-44-field_70-description\" required><div id=\"wpforms-44-field_70-description\" class=\"wpforms-field-description\">\u2022 Nous utilisons votre num\u00e9ro de S\u00e9curit\u00e9 sociale uniquement pour l'inscrire sur l'arr\u00eat de travail.<\/div><\/div><div id=\"wpforms-44-field_36-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"36\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4 last \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-44-field_108-container\" class=\"wpforms-field wpforms-field-payment-single\" data-field-id=\"108\"><label class=\"wpforms-field-label\">Prix <\/label><div class=\"wpforms-single-item-price-content\"><div class=\"wpforms-single-item-price wpforms-field-medium wpforms-payment-price\"> <span class=\"wpforms-price\">23,00 €<\/span><\/div><\/div><input type=\"hidden\" id=\"wpforms-44-field_108\" class=\"wpforms-field-medium wpforms-payment-price\" name=\"wpforms[fields][108]\" value=\"23,00 €\"><\/div><div id=\"wpforms-44-field_111-container\" class=\"wpforms-field wpforms-field-stripe-credit-card\" data-field-id=\"111\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">formulation neutre, administrative <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-no-columns wpforms-field-medium \" data-sublabel-position=\"above\" data-link-email=\"78\" data-required=\"1\"><div id=\"wpforms-field-stripe-payment-element-44\"><\/div><input type=\"text\" class=\"wpforms-stripe-credit-card-hidden-input\" name=\"wpforms[stripe-credit-card-hidden-input-44]\" disabled style=\"display: none;\"><\/div><div id=\"wpforms-44-field_111-description\" class=\"wpforms-field-description\">Service administratif \u2013 transmission de dossier au professionnel partenaire\n<\/div><\/div><div id=\"wpforms-44-field_5-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"5\"><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"44\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-44\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Terminer\" aria-live=\"assertive\" value=\"wpforms-submit\">Terminer<\/button><img decoding=\"async\" src=\"https:\/\/app.assistfranceonline.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Chargement en cours\"><\/div><\/form><\/div> ')) {\r\n console.log(\"\u26a0\ufe0f Shortcode WPForms d\u00e9tect\u00e9 en texte brut. Sous WordPress, il sera remplac\u00e9 automatiquement.\");\r\n }\r\n<\/script>\r\n<\/body>\r\n<\/html>\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>Assit France Online AssistFranceOnline T\u00c9L\u00c9CONSULTATION SANS RENDEZ-VOUS \u2013 7J\/7 Obtenez votre arr\u00eat maladie en ligne. Rapide, simple et s\u00e9curis\u00e9. Commander […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-9","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/comments?post=9"}],"version-history":[{"count":237,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\/revisions"}],"predecessor-version":[{"id":602,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\/revisions\/602"}],"wp:attachment":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/media?parent=9"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

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\n\t\t\t\t\t\r\n\r\n\r\n \r\n \r\n Assit France Online<\/title>\r\n <link rel=\"stylesheet\" href=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/font-awesome\/6.0.0\/css\/all.min.css\">\r\n <style>\r\n * {\r\n margin: 0;\r\n padding: 0;\r\n box-sizing: border-box;\r\n }\r\n\r\n body {\r\n font-family: 'Inter', 'Segoe UI', system-ui, -apple-system, sans-serif;\r\n background: linear-gradient(145deg, #f0f4ff 0%, #e8effa 100%);\r\n overflow-x: hidden;\r\n color: #0a2540;\r\n }\r\n\r\n \/* Effets 3D globaux *\/\r\n .scene-3d {\r\n perspective: 1000px;\r\n }\r\n\r\n @keyframes float-soft {\r\n 0% { transform: translateY(0px) rotateX(0deg); }\r\n 50% { transform: translateY(-6px) rotateX(1deg); }\r\n 100% { transform: translateY(0px) rotateX(0deg); }\r\n }\r\n\r\n @keyframes glow-pulse {\r\n 0% { box-shadow: 0 20px 40px -12px rgba(0, 102, 204, 0.15); }\r\n 50% { box-shadow: 0 30px 55px -12px rgba(0, 102, 204, 0.3); }\r\n 100% { box-shadow: 0 20px 40px -12px rgba(0, 102, 204, 0.15); }\r\n }\r\n\r\n \/* Header verre 3D *\/\r\n .header-glass {\r\n position: sticky;\r\n top: 0;\r\n z-index: 100;\r\n background: rgba(255, 255, 255, 0.85);\r\n backdrop-filter: blur(16px);\r\n border-bottom: 1px solid rgba(255,255,255,0.6);\r\n box-shadow: 0 4px 20px rgba(0,0,0,0.02);\r\n }\r\n\r\n .logo-3d {\r\n font-size: 1.8rem;\r\n font-weight: 800;\r\n letter-spacing: -0.5px;\r\n }\r\n\r\n .logo-3d .blue {\r\n background: linear-gradient(135deg, #0066cc, #0f5cff);\r\n -webkit-background-clip: text;\r\n background-clip: text;\r\n color: transparent;\r\n }\r\n\r\n .logo-3d .green {\r\n background: linear-gradient(135deg, #00b67a, #009966);\r\n -webkit-background-clip: text;\r\n background-clip: text;\r\n color: transparent;\r\n }\r\n\r\n \/* Carte principale 3D *\/\r\n .card-3d {\r\n background: rgba(255, 255, 255, 0.97);\r\n backdrop-filter: blur(2px);\r\n border-radius: 48px;\r\n padding: 40px 32px;\r\n box-shadow: 0 35px 55px -20px rgba(0, 0, 0, 0.2), 0 0 0 1px rgba(255,255,255,0.8);\r\n transform: translateZ(15px) rotateX(1deg);\r\n transition: transform 0.35s ease, box-shadow 0.35s ease;\r\n animation: float-soft 5s infinite ease-in-out;\r\n }\r\n\r\n .card-3d:hover {\r\n transform: translateZ(25px) rotateX(0deg);\r\n box-shadow: 0 45px 70px -18px rgba(0, 0, 0, 0.25);\r\n }\r\n\r\n \/* Badges *\/\r\n .badge-modern {\r\n background: linear-gradient(115deg, #ffffff, #f5f9ff);\r\n border-radius: 60px;\r\n padding: 8px 20px;\r\n font-size: 0.8rem;\r\n font-weight: 600;\r\n color: #0066cc;\r\n display: inline-block;\r\n box-shadow: 0 4px 10px rgba(0,0,0,0.03), inset 0 1px 0 white;\r\n }\r\n\r\n \/* Statistiques flottantes *\/\r\n .stat-3d {\r\n background: rgba(255,255,255,0.9);\r\n backdrop-filter: blur(12px);\r\n border-radius: 32px;\r\n padding: 20px;\r\n text-align: center;\r\n transition: all 0.25s;\r\n border: 1px solid rgba(255,255,255,0.6);\r\n box-shadow: 0 15px 30px -12px rgba(0,0,0,0.08);\r\n }\r\n\r\n .stat-3d:hover {\r\n transform: translateY(-5px);\r\n background: white;\r\n }\r\n\r\n \/* \u00c9tapes 3D *\/\r\n .step-3d {\r\n background: white;\r\n border-radius: 36px;\r\n padding: 28px 20px;\r\n transition: all 0.3s cubic-bezier(0.2, 0.9, 0.4, 1.1);\r\n box-shadow: 0 20px 35px -12px rgba(0,0,0,0.1);\r\n }\r\n\r\n .step-3d:hover {\r\n transform: translateY(-8px) scale(1.02);\r\n box-shadow: 0 30px 45px -12px rgba(0,102,204,0.2);\r\n }\r\n\r\n .step-circle {\r\n width: 56px;\r\n height: 56px;\r\n background: linear-gradient(145deg, #0066cc, #0f5cff);\r\n border-radius: 30px;\r\n display: flex;\r\n align-items: center;\r\n justify-content: center;\r\n font-size: 1.8rem;\r\n font-weight: 800;\r\n color: white;\r\n margin-bottom: 20px;\r\n box-shadow: 0 12px 18px -6px rgba(0,102,204,0.4);\r\n }\r\n\r\n \/* Features 3D *\/\r\n .feature-3d {\r\n background: rgba(255,255,255,0.85);\r\n backdrop-filter: blur(8px);\r\n border-radius: 28px;\r\n padding: 20px 16px;\r\n text-align: center;\r\n transition: 0.2s;\r\n border: 1px solid rgba(255,255,255,0.7);\r\n }\r\n\r\n .feature-3d i {\r\n font-size: 2rem;\r\n color: #0066cc;\r\n margin-bottom: 12px;\r\n }\r\n\r\n \/* CTA final *\/\r\n .cta-glow {\r\n background: linear-gradient(135deg, #00b67a, #009966);\r\n border: none;\r\n padding: 16px 32px;\r\n border-radius: 60px;\r\n font-weight: 700;\r\n font-size: 1.1rem;\r\n color: white;\r\n display: inline-block;\r\n text-decoration: none;\r\n box-shadow: 0 15px 30px -8px rgba(0,182,122,0.4);\r\n transition: all 0.2s;\r\n }\r\n\r\n .cta-glow:active {\r\n transform: scale(0.97);\r\n }\r\n\r\n \/* Container *\/\r\n .container {\r\n max-width: 1200px;\r\n margin: 0 auto;\r\n padding: 0 24px;\r\n }\r\n\r\n \/* Zone du formulaire WPForms *\/\r\n .wpforms-integration {\r\n width: 100%;\r\n }\r\n\r\n \/* Aucun style intrusif pour le formulaire r\u00e9el *\/\r\n .wpforms-integration .wpforms-container {\r\n width: 100%;\r\n }\r\n\r\n \/* Responsive *\/\r\n @media (max-width: 768px) {\r\n .container {\r\n padding: 0 16px;\r\n }\r\n .card-3d {\r\n padding: 28px 20px;\r\n border-radius: 32px;\r\n }\r\n .step-circle {\r\n width: 48px;\r\n height: 48px;\r\n font-size: 1.5rem;\r\n }\r\n .logo-3d {\r\n font-size: 1.5rem;\r\n }\r\n }\r\n\r\n \/* D\u00e9cors flottants 3D *\/\r\n .orb {\r\n position: fixed;\r\n border-radius: 50%;\r\n filter: blur(70px);\r\n z-index: -1;\r\n pointer-events: none;\r\n }\r\n\r\n footer {\r\n text-align: center;\r\n padding: 40px 20px 30px;\r\n font-size: 0.75rem;\r\n color: #5a6e8a;\r\n }\r\n <\/style>\r\n \r\n<script>\r\n gtag('event', 'conversion', {\r\n 'send_to': 'AW-17946752989\/etzDCPuYr_cbEN3v1u1C',\r\n 'value': 1.0,\r\n 'currency': 'EUR'\r\n });\r\n<\/script>\r\n\r\n<\/head>\r\n<body>\r\n\r\n<div class=\"orb\" style=\"width: 350px; height: 350px; background: radial-gradient(circle, rgba(0,102,204,0.08), transparent); top: -120px; left: -80px;\"><\/div>\r\n<div class=\"orb\" style=\"width: 400px; height: 400px; background: radial-gradient(circle, rgba(0,182,122,0.06), transparent); bottom: -100px; right: -100px;\"><\/div>\r\n\r\n<header class=\"header-glass\">\r\n <div class=\"container\">\r\n <div style=\"display: flex; justify-content: space-between; align-items: center; padding: 16px 0;\">\r\n <div class=\"logo-3d\">\r\n <span class=\"blue\">AssistFrance<\/span><span class=\"green\">Online<\/span>\r\n <\/div>\r\n <div style=\"font-size: 0.85rem; background: rgba(0,102,204,0.1); padding: 6px 14px; border-radius: 40px;\">\r\n <i class=\"fas fa-shield-alt\"><\/i> T\u00c9L\u00c9CONSULTATION SANS RENDEZ-VOUS \u2013 7J\/7\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n<\/header>\r\n\r\n<main class=\"scene-3d\" style=\"padding: 45px 0 60px;\">\r\n <div class=\"container\">\r\n \r\n <div class=\"card-3d\" style=\"margin-bottom: 50px;\">\r\n <div style=\"text-align: center; margin-bottom: 30px;\">\r\n <span class=\"badge-modern\"><i class=\"fas fa-stethoscope\"><\/i> Obtenez votre arr\u00eat maladie en ligne. Rapide, simple et s\u00e9curis\u00e9.<\/span>\r\n <h1 style=\"font-size: 2rem; margin-top: 24px; font-weight: 800; background: linear-gradient(125deg, #0a2540, #0066cc); -webkit-background-clip: text; background-clip: text; color: transparent;\">Commander votre arr\u00eat maladie<br>en 5 minutes<\/h1>\r\n <p style=\"color: #456e93; margin-top: 12px; font-size: 1rem;\">Remplissez le court formulaire maintenant, recevez votre arr\u00eat<\/p>\r\n <\/div>\r\n\r\n \r\n <div class=\"wpforms-integration\">\r\n \r\n <div id=\"wpforms-shortcode-container\">\r\n \r\n <style id=\"wpforms-css-vars-44\">\n\t\t\t\t#wpforms-44 {\n\t\t\t\t--wpforms-field-border-radius: 22px;\n--wpforms-field-border-color: #073eff;\n--wpforms-field-border-color-spare: #073eff;\n--wpforms-field-text-color: #666666;\n--wpforms-label-color: #666666;\n--wpforms-label-sublabel-color: #666666;\n--wpforms-label-error-color: #da0000;\n--wpforms-button-border-radius: 100px;\n--wpforms-button-background-color: #073eff;\n--wpforms-button-border-color: #073eff;\n--wpforms-container-padding: 60px;\n--wpforms-container-border-style: solid;\n--wpforms-container-border-radius: 50px;\n--wpforms-container-border-color: #f3f3f3;\n--wpforms-background-color: #ffffff;\n--wpforms-page-break-color: #073eff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: 0px 30px 50px -10px rgba(0, 0, 0, 0.15);\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-stripe wpforms-render-modern\" id=\"wpforms-44\"><form id=\"wpforms-form-44\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"44\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/9\" data-token=\"a97a3eed3bc757defd455fd246c35b98\" data-token-time=\"1780673287\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/div><div class=\"wpforms-page-indicator circles\" data-indicator=\"circles\" data-indicator-color=\"#3b48b8\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"4\" tabindex=\"-1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#3b48b8\">1<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-2\"><span class=\"wpforms-page-indicator-page-number\">2<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-3\"><span class=\"wpforms-page-indicator-page-number\">3<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-4\"><span class=\"wpforms-page-indicator-page-number\">4<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-44-field_4-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"4\"><\/div><div id=\"wpforms-44-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_14\">\ud83e\udda0 Quelle maladie vous concerne ? *<\/label><select id=\"wpforms-44-field_14\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][14]\"><option value=\"\" class=\"placeholder\" disabled selected='selected'><\/option><option value=\"Veuillez s\u00e9lectionner\" class=\"choice-1 depth-1\" >Veuillez s\u00e9lectionner<\/option><option value=\"Gastro-ent\u00e9rite\" class=\"choice-2 depth-1\" >Gastro-ent\u00e9rite<\/option><option value=\"Sympt\u00f4me Corona\" class=\"choice-3 depth-1\" >Sympt\u00f4me Corona<\/option><option value=\"Stress\" class=\"choice-7 depth-1\" >Stress<\/option><option value=\"Migraine\" class=\"choice-6 depth-1\" >Migraine<\/option><option value=\"Mal de dos\" class=\"choice-5 depth-1\" >Mal de dos<\/option><option value=\"Douleurs menstruelles\" class=\"choice-4 depth-1\" >Douleurs menstruelles<\/option><option value=\"Cystite\" class=\"choice-8 depth-1\" >Cystite<\/option><option value=\"Blessures\" class=\"choice-9 depth-1\" >Blessures<\/option><option value=\"Douleurs abdominales \/ pelviennes\" class=\"choice-10 depth-1\" >Douleurs abdominales \/ pelviennes<\/option><option value=\"Hypertension\" class=\"choice-11 depth-1\" >Hypertension<\/option><option value=\"Allergie\" class=\"choice-12 depth-1\" >Allergie<\/option><option value=\"Probl\u00e8mes dentaires\" class=\"choice-15 depth-1\" >Probl\u00e8mes dentaires<\/option><option value=\"Maux de t\u00eate\" class=\"choice-14 depth-1\" >Maux de t\u00eate<\/option><option value=\"Naus\u00e9es\/ Vomissements\" class=\"choice-16 depth-1\" >Naus\u00e9es\/ Vomissements<\/option><option value=\"Gastrite\" class=\"choice-17 depth-1\" >Gastrite<\/option><option value=\"Probl\u00e8mes articulaires\" class=\"choice-18 depth-1\" >Probl\u00e8mes articulaires<\/option><option value=\"Syndrome d\u2019\u00e9puisement\" class=\"choice-20 depth-1\" >Syndrome d\u2019\u00e9puisement<\/option><\/select><div id=\"wpforms-44-field_14-description\" class=\"wpforms-field-description\">Une seule possibilit\u00e9<\/div><\/div><div id=\"wpforms-44-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 ? *<\/legend><ul id=\"wpforms-44-field_16\" class=\"wpforms-icon-choices wpforms-icon-choices-default wpforms-icon-choices-small\" data-choice-limit=\"1\" style=\"--wpforms-icon-choices-color: #066aab;\"><li class=\"choice-1 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_1\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM369 209c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-111 111-47-47c-9.4-9.4-24.6-9.4-33.9 0s-9.4 24.6 0 33.9l64 64c9.4 9.4 24.6 9.4 33.9 0L369 209z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_1\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_16_1-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Oui<\/span>\n\t\t\t<\/label><\/li><li class=\"choice-2 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_2\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM175 175c-9.4 9.4-9.4 24.6 0 33.9l47 47-47 47c-9.4 9.4-9.4 24.6 0 33.9s24.6 9.4 33.9 0l47-47 47 47c9.4 9.4 24.6 9.4 33.9 0s9.4-24.6 0-33.9l-47-47 47-47c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-47 47-47-47c-9.4-9.4-24.6-9.4-33.9 0z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_2\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_16_2-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Non<\/span>\n\t\t\t<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\"> S\u00e9lectionnez vos sympt\u00f4mes : *<\/legend><ul id=\"wpforms-44-field_17\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fi\u00e8vre\" aria-errormessage=\"wpforms-44-field_17_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_1\">Fi\u00e8vre<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Naus\u00e9es\" aria-errormessage=\"wpforms-44-field_17_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_2\">Naus\u00e9es<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Diarrh\u00e9e\" aria-errormessage=\"wpforms-44-field_17_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_3\">Diarrh\u00e9e<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux sans mucus\" aria-errormessage=\"wpforms-44-field_17_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_4\">Toux sans mucus<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux avec mucosit\u00e9s\" aria-errormessage=\"wpforms-44-field_17_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_5\">Toux avec mucosit\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Malaise\" aria-errormessage=\"wpforms-44-field_17_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_6\">Malaise<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fatigue\" aria-errormessage=\"wpforms-44-field_17_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_7\">Fatigue<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_9\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Hypertension art\u00e9rielle\" aria-errormessage=\"wpforms-44-field_17_9-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_9\">Hypertension art\u00e9rielle<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_10\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Stress\" aria-errormessage=\"wpforms-44-field_17_10-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_10\">Stress<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_11\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Troubles du sommeil\" aria-errormessage=\"wpforms-44-field_17_11-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_11\">Troubles du sommeil<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd12 Sympt\u00f4mes principaux *<\/legend><ul id=\"wpforms-44-field_24\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"T\u00eate\" aria-errormessage=\"wpforms-44-field_24_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_1\">T\u00eate<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Ventre\" aria-errormessage=\"wpforms-44-field_24_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_2\">Ventre<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dent\" aria-errormessage=\"wpforms-44-field_24_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_3\">Dent<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dos\" aria-errormessage=\"wpforms-44-field_24_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_4\">Dos<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Cou\" aria-errormessage=\"wpforms-44-field_24_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_7\">Cou<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Membres\" aria-errormessage=\"wpforms-44-field_24_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_6\">Membres<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Oreille\" aria-errormessage=\"wpforms-44-field_24_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_5\">Oreille<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Organe sexuel\" aria-errormessage=\"wpforms-44-field_24_8-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_8\">Organe sexuel<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udde0 Intensit\u00e9 de la douleur *<\/legend><ul id=\"wpforms-44-field_27\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_27_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_27_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_2\">Non<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Peut-\u00eatre\" aria-errormessage=\"wpforms-44-field_27_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_3\">Peut-\u00eatre<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_30\">\ud83d\udc8a M\u00e9dicaments d\u00e9j\u00e0 pris ?<\/label><textarea id=\"wpforms-44-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-44-field_30-error\" ><\/textarea><\/div><div id=\"wpforms-44-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\">\u26a0\ufe0f Pr\u00e9sentez-vous un facteur de risque ?<\/legend><ul id=\"wpforms-44-field_31\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_31_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_31_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd14 Votre employeur est-il insatisfait de votre travail ?<\/legend><ul id=\"wpforms-44-field_35\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_35_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_35_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-44-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">\ud83c\udd95 Type de demande <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_37\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-44-field_37_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Initial\" aria-errormessage=\"wpforms-44-field_37_1-error\" required checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_1\">Initial<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_37_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Prolongation\" aria-errormessage=\"wpforms-44-field_37_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_2\">Prolongation<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_41\">\ud83d\udc54 Votre profession * <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-44-field_41\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-44-field_41-error\" required><\/textarea><\/div><div id=\"wpforms-44-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">\u00c0 quel point votre travail est-il physiquement exigeant ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_46\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"L\u00e9ger\" aria-errormessage=\"wpforms-44-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_1\">L\u00e9ger<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Moyen\" aria-errormessage=\"wpforms-44-field_46_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_2\">Moyen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Elev\u00e9\" aria-errormessage=\"wpforms-44-field_46_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_3\">Elev\u00e9<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_48-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"48\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udcc5 Dates souhait\u00e9es\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_49-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_49\">D\u00e9but: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_49\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][49][date]\" aria-errormessage=\"wpforms-44-field_49-error\" aria-describedby=\"wpforms-44-field_49-description\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-44-field_49-description\" class=\"wpforms-field-description\">\u201cVeuillez s\u00e9lectionner une date comprise entre aujourd\u2019hui et les 5 derniers jours.\"<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_50-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_50\">Fin: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_50\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][50][date]\" aria-errormessage=\"wpforms-44-field_50-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_52-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"52\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udc64 Identit\u00e9\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_53-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][53][first]\" placeholder=\"Votre Pr\u00e9nom\" aria-errormessage=\"wpforms-44-field_53-error\" required><label for=\"wpforms-44-field_53\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][53][last]\" placeholder=\"Votre Nom\" aria-errormessage=\"wpforms-44-field_53-last-error\" required><label for=\"wpforms-44-field_53-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_56-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_56\">\ud83d\udcf1T\u00e9l\u00e9phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-44-field_56\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][56]\" aria-label=\"\ud83d\udcf1T\u00e9l\u00e9phone \" aria-errormessage=\"wpforms-44-field_56-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_55-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_55\">\ud83c\udf82 Date de naissance : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_55\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][55][date]\" aria-errormessage=\"wpforms-44-field_55-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_78-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_78\">\ud83d\udce9 E-mail <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-44-field_78\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][78]\" spellcheck=\"false\" aria-errormessage=\"wpforms-44-field_78-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_40-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"40\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-44-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"51\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83c\udfe0 Adresse postale\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_61-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label\">Adresse: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-44-field_61\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][61][address1]\" aria-errormessage=\"wpforms-44-field_61-error\" required><label for=\"wpforms-44-field_61\" class=\"wpforms-field-sublabel after\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][61][city]\" aria-errormessage=\"wpforms-44-field_61-city-error\" required><label for=\"wpforms-44-field_61-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_61-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][61][state]\" aria-errormessage=\"wpforms-44-field_61-state-error\" required><label for=\"wpforms-44-field_61-state\" class=\"wpforms-field-sublabel after\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][61][postal]\" aria-errormessage=\"wpforms-44-field_61-postal-error\" required><label for=\"wpforms-44-field_61-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_82-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_82\">Pays <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-44-field_82\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][82]\" placeholder=\"France\" aria-errormessage=\"wpforms-44-field_82-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_70-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_70\">\ud83e\udeaa ID S\u00e9curit\u00e9 Sociale <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-44-field_70\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][70]\" step=\"any\" aria-errormessage=\"wpforms-44-field_70-error\" aria-describedby=\"wpforms-44-field_70-description\" required><div id=\"wpforms-44-field_70-description\" class=\"wpforms-field-description\">\u2022 Nous utilisons votre num\u00e9ro de S\u00e9curit\u00e9 sociale uniquement pour l'inscrire sur l'arr\u00eat de travail.<\/div><\/div><div id=\"wpforms-44-field_36-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"36\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4 last \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-44-field_108-container\" class=\"wpforms-field wpforms-field-payment-single\" data-field-id=\"108\"><label class=\"wpforms-field-label\">Prix <\/label><div class=\"wpforms-single-item-price-content\"><div class=\"wpforms-single-item-price wpforms-field-medium wpforms-payment-price\"> <span class=\"wpforms-price\">23,00 €<\/span><\/div><\/div><input type=\"hidden\" id=\"wpforms-44-field_108\" class=\"wpforms-field-medium wpforms-payment-price\" name=\"wpforms[fields][108]\" value=\"23,00 €\"><\/div><div id=\"wpforms-44-field_111-container\" class=\"wpforms-field wpforms-field-stripe-credit-card\" data-field-id=\"111\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">formulation neutre, administrative <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-no-columns wpforms-field-medium \" data-sublabel-position=\"above\" data-link-email=\"78\" data-required=\"1\"><div id=\"wpforms-field-stripe-payment-element-44\"><\/div><input type=\"text\" class=\"wpforms-stripe-credit-card-hidden-input\" name=\"wpforms[stripe-credit-card-hidden-input-44]\" disabled style=\"display: none;\"><\/div><div id=\"wpforms-44-field_111-description\" class=\"wpforms-field-description\">Service administratif \u2013 transmission de dossier au professionnel partenaire\n<\/div><\/div><div id=\"wpforms-44-field_5-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"5\"><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"44\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-44\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Terminer\" aria-live=\"assertive\" value=\"wpforms-submit\">Terminer<\/button><img decoding=\"async\" src=\"https:\/\/app.assistfranceonline.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Chargement en cours\"><\/div><\/form><\/div> \r\n <\/div>\r\n \r\n <div style=\"text-align: center; margin-top: 12px; font-size: 11px; color: #7c8ea0;\">\r\n <i class=\"fas fa-lock\"><\/i> Votre paiement est s\u00e9curis\u00e9 par Viva Payments.\r\n <\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div style=\"display: grid; grid-template-columns: repeat(auto-fit, minmax(180px, 1fr)); gap: 24px; margin-bottom: 60px;\">\r\n <div class=\"stat-3d\"><i class=\"fas fa-file-medical\" style=\"font-size: 2rem; color:#0066cc;\"><\/i><h2 style=\"font-size: 2rem; margin: 8px 0 0;\">+25k<\/h2><p>Arr\u00eats d\u00e9livr\u00e9s<\/p><\/div>\r\n <div class=\"stat-3d\"><i class=\"fas fa-hourglass-half\" style=\"font-size: 2rem; color:#0066cc;\"><\/i><h2 style=\"font-size: 2rem; margin: 8px 0 0;\">5 min<\/h2><p>R\u00e9ponse <\/p><\/div>\r\n <div class=\"stat-3d\"><i class=\"fas fa-star\" style=\"font-size: 2rem; color:#0066cc;\"><\/i><h2 style=\"font-size: 2rem; margin: 8px 0 0;\">98%<\/h2><p>Satisfaction<\/p><\/div>\r\n <\/div>\r\n\r\n \r\n <h2 style=\"text-align: center; font-size: 1.9rem; margin-bottom: 40px;\">\u2728 Comment \u00e7a marche ? \u2728<\/h2>\r\n <div style=\"display: flex; flex-wrap: wrap; gap: 30px; justify-content: center; margin-bottom: 70px;\">\r\n <div class=\"step-3d\" style=\"flex: 1; min-width: 220px;\">\r\n <div class=\"step-circle\">1<\/div>\r\n <i class=\"fas fa-edit\" style=\"font-size: 2rem; color:#0066cc; margin-bottom: 12px; display: block;\"><\/i>\r\n <h3>Questionnaire simple<\/h3>\r\n <p style=\"color:#5a6e8a;\">R\u00e9pondez en quelques minutes sur votre \u00e9tat<\/p>\r\n <\/div>\r\n <div class=\"step-3d\" style=\"flex: 1; min-width: 220px;\">\r\n <div class=\"step-circle\">2<\/div>\r\n <i class=\"fas fa-user-md\" style=\"font-size: 2rem; color:#0066cc; margin-bottom: 12px; display: block;\"><\/i>\r\n <h3>Recevez votre PDF<\/h3>\r\n <p style=\"color:#5a6e8a;\">Votre arr\u00eat maladie pr\u00e9-rempli sera envoy\u00e9 par e-mail,<\/p>\r\n <\/div>\r\n <div class=\"step-3d\" style=\"flex: 1; min-width: 220px;\">\r\n <div class=\"step-circle\">3<\/div>\r\n <i class=\"fas fa-file-pdf\" style=\"font-size: 2rem; color:#0066cc; margin-bottom: 12px; display: block;\"><\/i>\r\n <h3>PDF imm\u00e9diat<\/h3>\r\n <p style=\"color:#5a6e8a;\">Recevez votre certificat par email<\/p>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div style=\"background: linear-gradient(120deg, rgba(255,255,255,0.5), rgba(240,248,255,0.6)); border-radius: 55px; padding: 35px 25px; margin-bottom: 50px;\">\r\n <h2 style=\"text-align: center; margin-bottom: 32px;\">Pourquoi <strong style=\"color:#0066cc;\">nous choisir<\/strong> ?<\/h2>\r\n <div style=\"display: grid; grid-template-columns: repeat(auto-fit, minmax(150px, 1fr)); gap: 20px;\">\r\n <div class=\"feature-3d\"><i class=\"fas fa-bolt\"><\/i><h4>Rapide<\/h4><small>Sans d\u00e9placement<\/small><\/div>\r\n <div class=\"feature-3d\"><i class=\"fas fa-shield-alt\"><\/i><h4>S\u00e9curis\u00e9<\/h4><small>Donn\u00e9es confidentielles<\/small><\/div>\r\n \r\n <div class=\"feature-3d\"><i class=\"fas fa-clock\"><\/i><h4>24\/7<\/h4><small>Service disponible<\/small><\/div>\r\n <div class=\"feature-3d\"><i class=\"fas fa-building\"><\/i><h4>Accept\u00e9 partout<\/h4><small>Validit\u00e9 employeur<\/small><\/div>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"card-3d\" style=\"background: white; text-align: center; animation: glow-pulse 3s infinite;\">\r\n <i class=\"fas fa-quote-left\" style=\"font-size: 2rem; color: #00b67a; opacity: 0.6;\"><\/i>\r\n <p style=\"font-size: 1.1rem; max-width: 500px; margin: 16px auto; font-style: italic;\">\"Arr\u00eat re\u00e7u rapidement, site clair et fiable. Je recommande !\"<\/p>\r\n <p><strong>\u2014 Sophie M.<\/strong> \u2b50\u2b50\u2b50\u2b50\u2b50<\/p>\r\n <div style=\"margin: 28px 0 10px;\">\r\n <a href=\"#\" class=\"cta-glow\"><i class=\"fas fa-arrow-right\"><\/i> Obtenir mon arr\u00eat maintenant<\/a>\r\n <\/div>\r\n <p style=\"font-size: 0.7rem; margin-top: 16px;\">\ud83e\ude7a Arr\u00eat maladie officiel \u00b723\u20ac seulement<\/p>\r\n <\/div>\r\n\r\n \r\n <div style=\"margin-top: 45px; background: rgba(255,255,245,0.7); border-radius: 40px; padding: 28px;\">\r\n <h3><i class=\"fas fa-question-circle\"><\/i> Questions fr\u00e9quentes<\/h3>\r\n <details style=\"margin-top: 15px; background: white; border-radius: 50px; padding: 12px 20px;\"><summary style=\"font-weight: 600;\">L'arr\u00eat maladie en ligne est-il l\u00e9gal ?<\/summary><p style=\"margin-top: 8px;\">Oui, 100% conforme. R\u00e9alis\u00e9 par des m\u00e9decins inscrits \u00e0 l'Ordre.<\/p><\/details>\r\n <details style=\"margin-top: 12px; background: white; border-radius: 50px; padding: 12px 20px;\"><summary style=\"font-weight: 600;\">Quel est le d\u00e9lai d'obtention ?<\/summary><p style=\"margin-top: 8px;\">Sous 24h maximum, souvent en quelques heures.<\/p><\/details>\r\n <\/div>\r\n <\/div>\r\n<\/main>\r\n\r\n<footer>\r\n <p><i class=\"fas fa-heart\" style=\"color:#0066cc;\"><\/i> Assistfranceonline\u00a9 2026 \u2014 Service \r\nArr\u00eat de Travail En Ligne<\/p>\r\n \r\n<\/footer>\r\n\r\n<script>\r\n \/\/ V\u00e9rification simple : si le shortcode est remplac\u00e9 par WordPress, tout fonctionne.\r\n \/\/ Aucune alt\u00e9ration du formulaire natif WPForms.\r\n console.log(\"\u2705 Design 3D actif - Emplacement r\u00e9serv\u00e9 pour \");\r\n \/\/ Rappel silencieux dans la console\r\n const container = document.getElementById('wpforms-shortcode-container');\r\n if(container && container.innerText.includes('<style id=\"wpforms-css-vars-44\">\n\t\t\t\t#wpforms-44 {\n\t\t\t\t--wpforms-field-border-radius: 22px;\n--wpforms-field-border-color: #073eff;\n--wpforms-field-border-color-spare: #073eff;\n--wpforms-field-text-color: #666666;\n--wpforms-label-color: #666666;\n--wpforms-label-sublabel-color: #666666;\n--wpforms-label-error-color: #da0000;\n--wpforms-button-border-radius: 100px;\n--wpforms-button-background-color: #073eff;\n--wpforms-button-border-color: #073eff;\n--wpforms-container-padding: 60px;\n--wpforms-container-border-style: solid;\n--wpforms-container-border-radius: 50px;\n--wpforms-container-border-color: #f3f3f3;\n--wpforms-background-color: #ffffff;\n--wpforms-page-break-color: #073eff;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: 0px 30px 50px -10px rgba(0, 0, 0, 0.15);\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-stripe wpforms-render-modern\" id=\"wpforms-44\"><form id=\"wpforms-form-44\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"44\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/9\" data-token=\"a97a3eed3bc757defd455fd246c35b98\" data-token-time=\"1780673287\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/div><div class=\"wpforms-page-indicator circles\" data-indicator=\"circles\" data-indicator-color=\"#3b48b8\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"4\" tabindex=\"-1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#3b48b8\">1<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-2\"><span class=\"wpforms-page-indicator-page-number\">2<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-3\"><span class=\"wpforms-page-indicator-page-number\">3<\/span><\/div><div class=\"wpforms-page-indicator-page wpforms-page-indicator-page-4\"><span class=\"wpforms-page-indicator-page-number\">4<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-44-field_4-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"4\"><\/div><div id=\"wpforms-44-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_14\">\ud83e\udda0 Quelle maladie vous concerne ? *<\/label><select id=\"wpforms-44-field_14\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][14]\"><option value=\"\" class=\"placeholder\" disabled selected='selected'><\/option><option value=\"Veuillez s\u00e9lectionner\" class=\"choice-1 depth-1\" >Veuillez s\u00e9lectionner<\/option><option value=\"Gastro-ent\u00e9rite\" class=\"choice-2 depth-1\" >Gastro-ent\u00e9rite<\/option><option value=\"Sympt\u00f4me Corona\" class=\"choice-3 depth-1\" >Sympt\u00f4me Corona<\/option><option value=\"Stress\" class=\"choice-7 depth-1\" >Stress<\/option><option value=\"Migraine\" class=\"choice-6 depth-1\" >Migraine<\/option><option value=\"Mal de dos\" class=\"choice-5 depth-1\" >Mal de dos<\/option><option value=\"Douleurs menstruelles\" class=\"choice-4 depth-1\" >Douleurs menstruelles<\/option><option value=\"Cystite\" class=\"choice-8 depth-1\" >Cystite<\/option><option value=\"Blessures\" class=\"choice-9 depth-1\" >Blessures<\/option><option value=\"Douleurs abdominales \/ pelviennes\" class=\"choice-10 depth-1\" >Douleurs abdominales \/ pelviennes<\/option><option value=\"Hypertension\" class=\"choice-11 depth-1\" >Hypertension<\/option><option value=\"Allergie\" class=\"choice-12 depth-1\" >Allergie<\/option><option value=\"Probl\u00e8mes dentaires\" class=\"choice-15 depth-1\" >Probl\u00e8mes dentaires<\/option><option value=\"Maux de t\u00eate\" class=\"choice-14 depth-1\" >Maux de t\u00eate<\/option><option value=\"Naus\u00e9es\/ Vomissements\" class=\"choice-16 depth-1\" >Naus\u00e9es\/ Vomissements<\/option><option value=\"Gastrite\" class=\"choice-17 depth-1\" >Gastrite<\/option><option value=\"Probl\u00e8mes articulaires\" class=\"choice-18 depth-1\" >Probl\u00e8mes articulaires<\/option><option value=\"Syndrome d\u2019\u00e9puisement\" class=\"choice-20 depth-1\" >Syndrome d\u2019\u00e9puisement<\/option><\/select><div id=\"wpforms-44-field_14-description\" class=\"wpforms-field-description\">Une seule possibilit\u00e9<\/div><\/div><div id=\"wpforms-44-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 ? *<\/legend><ul id=\"wpforms-44-field_16\" class=\"wpforms-icon-choices wpforms-icon-choices-default wpforms-icon-choices-small\" data-choice-limit=\"1\" style=\"--wpforms-icon-choices-color: #066aab;\"><li class=\"choice-1 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_1\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM369 209c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-111 111-47-47c-9.4-9.4-24.6-9.4-33.9 0s-9.4 24.6 0 33.9l64 64c9.4 9.4 24.6 9.4 33.9 0L369 209z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_1\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_16_1-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Oui<\/span>\n\t\t\t<\/label><\/li><li class=\"choice-2 depth-1 wpforms-icon-choices-item\"><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_2\">\n\t\t\t\t<span class=\"wpforms-icon-choices-icon\">\n\t\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"40\" height=\"32\" viewBox=\"0 0 512 512\"><path d=\"M256 48a208 208 0 1 1 0 416 208 208 0 1 1 0-416zm0 464A256 256 0 1 0 256 0a256 256 0 1 0 0 512zM175 175c-9.4 9.4-9.4 24.6 0 33.9l47 47-47 47c-9.4 9.4-9.4 24.6 0 33.9s24.6 9.4 33.9 0l47-47 47 47c9.4 9.4 24.6 9.4 33.9 0s9.4-24.6 0-33.9l-47-47 47-47c9.4-9.4 9.4-24.6 0-33.9s-24.6-9.4-33.9 0l-47 47-47-47c-9.4-9.4-24.6-9.4-33.9 0z\"\/><\/svg>\n\t\t\t\t\t<span class=\"wpforms-icon-choices-icon-bg\"><\/span>\n\t\t\t\t<\/span>\n\t\t\t\t<input type=\"checkbox\" id=\"wpforms-44-field_16_2\" class=\"wpforms-screen-reader-element\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_16_2-error\" >\n\t\t\t\t<span class=\"wpforms-icon-choices-label\">Non<\/span>\n\t\t\t<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\"> S\u00e9lectionnez vos sympt\u00f4mes : *<\/legend><ul id=\"wpforms-44-field_17\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fi\u00e8vre\" aria-errormessage=\"wpforms-44-field_17_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_1\">Fi\u00e8vre<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Naus\u00e9es\" aria-errormessage=\"wpforms-44-field_17_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_2\">Naus\u00e9es<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Diarrh\u00e9e\" aria-errormessage=\"wpforms-44-field_17_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_3\">Diarrh\u00e9e<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux sans mucus\" aria-errormessage=\"wpforms-44-field_17_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_4\">Toux sans mucus<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Toux avec mucosit\u00e9s\" aria-errormessage=\"wpforms-44-field_17_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_5\">Toux avec mucosit\u00e9s<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Malaise\" aria-errormessage=\"wpforms-44-field_17_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_6\">Malaise<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Fatigue\" aria-errormessage=\"wpforms-44-field_17_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_7\">Fatigue<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_9\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Hypertension art\u00e9rielle\" aria-errormessage=\"wpforms-44-field_17_9-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_9\">Hypertension art\u00e9rielle<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_10\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Stress\" aria-errormessage=\"wpforms-44-field_17_10-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_10\">Stress<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_11\" data-rule-check-limit=\"true\" name=\"wpforms[fields][17][]\" value=\"Troubles du sommeil\" aria-errormessage=\"wpforms-44-field_17_11-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_11\">Troubles du sommeil<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd12 Sympt\u00f4mes principaux *<\/legend><ul id=\"wpforms-44-field_24\" data-choice-limit=\"2\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"T\u00eate\" aria-errormessage=\"wpforms-44-field_24_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_1\">T\u00eate<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Ventre\" aria-errormessage=\"wpforms-44-field_24_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_2\">Ventre<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dent\" aria-errormessage=\"wpforms-44-field_24_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_3\">Dent<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_4\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Dos\" aria-errormessage=\"wpforms-44-field_24_4-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_4\">Dos<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_7\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Cou\" aria-errormessage=\"wpforms-44-field_24_7-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_7\">Cou<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_6\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Membres\" aria-errormessage=\"wpforms-44-field_24_6-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_6\">Membres<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_5\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Oreille\" aria-errormessage=\"wpforms-44-field_24_5-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_5\">Oreille<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_8\" data-rule-check-limit=\"true\" name=\"wpforms[fields][24][]\" value=\"Organe sexuel\" aria-errormessage=\"wpforms-44-field_24_8-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_8\">Organe sexuel<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_27-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udde0 Intensit\u00e9 de la douleur *<\/legend><ul id=\"wpforms-44-field_27\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_27_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_27_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_2\">Non<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_27_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][27][]\" value=\"Peut-\u00eatre\" aria-errormessage=\"wpforms-44-field_27_3-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_3\">Peut-\u00eatre<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_30-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_30\">\ud83d\udc8a M\u00e9dicaments d\u00e9j\u00e0 pris ?<\/label><textarea id=\"wpforms-44-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-44-field_30-error\" ><\/textarea><\/div><div id=\"wpforms-44-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label\">\u26a0\ufe0f Pr\u00e9sentez-vous un facteur de risque ?<\/legend><ul id=\"wpforms-44-field_31\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_31_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_31_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][31][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_31_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_35-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"35\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd14 Votre employeur est-il insatisfait de votre travail ?<\/legend><ul id=\"wpforms-44-field_35\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_35_1-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_35_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][35][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_35_2-error\" ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-44-field_37-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">\ud83c\udd95 Type de demande <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_37\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-44-field_37_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Initial\" aria-errormessage=\"wpforms-44-field_37_1-error\" required checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_1\">Initial<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_37_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Prolongation\" aria-errormessage=\"wpforms-44-field_37_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_2\">Prolongation<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_41\">\ud83d\udc54 Votre profession * <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-44-field_41\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-44-field_41-error\" required><\/textarea><\/div><div id=\"wpforms-44-field_46-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">\u00c0 quel point votre travail est-il physiquement exigeant ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_46\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"L\u00e9ger\" aria-errormessage=\"wpforms-44-field_46_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_1\">L\u00e9ger<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Moyen\" aria-errormessage=\"wpforms-44-field_46_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_2\">Moyen<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_46_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][46][]\" value=\"Elev\u00e9\" aria-errormessage=\"wpforms-44-field_46_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_46_3\">Elev\u00e9<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_48-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"48\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udcc5 Dates souhait\u00e9es\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_49-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_49\">D\u00e9but: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_49\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][49][date]\" aria-errormessage=\"wpforms-44-field_49-error\" aria-describedby=\"wpforms-44-field_49-description\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><div id=\"wpforms-44-field_49-description\" class=\"wpforms-field-description\">\u201cVeuillez s\u00e9lectionner une date comprise entre aujourd\u2019hui et les 5 derniers jours.\"<\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_50-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_50\">Fin: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_50\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][50][date]\" aria-errormessage=\"wpforms-44-field_50-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_52-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"52\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83d\udc64 Identit\u00e9\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_53-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"53\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\"> <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][53][first]\" placeholder=\"Votre Pr\u00e9nom\" aria-errormessage=\"wpforms-44-field_53-error\" required><label for=\"wpforms-44-field_53\" class=\"wpforms-field-sublabel after\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_53-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][53][last]\" placeholder=\"Votre Nom\" aria-errormessage=\"wpforms-44-field_53-last-error\" required><label for=\"wpforms-44-field_53-last\" class=\"wpforms-field-sublabel after\">Nom<\/label><\/div><\/div><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_56-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_56\">\ud83d\udcf1T\u00e9l\u00e9phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-44-field_56\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][56]\" aria-label=\"\ud83d\udcf1T\u00e9l\u00e9phone \" aria-errormessage=\"wpforms-44-field_56-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_55-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_55\">\ud83c\udf82 Date de naissance : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-44-field_55\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][55][date]\" aria-errormessage=\"wpforms-44-field_55-error\" required><a title=\"Effacer la date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Effacer la date\" style=\"display:none;\"><\/a><\/div><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_78-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_78\">\ud83d\udce9 E-mail <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-44-field_78\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][78]\" spellcheck=\"false\" aria-errormessage=\"wpforms-44-field_78-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_40-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"40\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Pr\u00e9c\u00e9dent<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3 \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-44-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"51\"><h3 class=\"wpforms-field-label\">\n\t\t\t\t\ud83c\udfe0 Adresse postale\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_61-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label\">Adresse: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-44-field_61\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][61][address1]\" aria-errormessage=\"wpforms-44-field_61-error\" required><label for=\"wpforms-44-field_61\" class=\"wpforms-field-sublabel after\">Adresse ligne\u00a01<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][61][city]\" aria-errormessage=\"wpforms-44-field_61-city-error\" required><label for=\"wpforms-44-field_61-city\" class=\"wpforms-field-sublabel after\">Ville<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-44-field_61-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][61][state]\" aria-errormessage=\"wpforms-44-field_61-state-error\" required><label for=\"wpforms-44-field_61-state\" class=\"wpforms-field-sublabel after\">\u00c9tat \/ Province \/ R\u00e9gion<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-44-field_61-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][61][postal]\" aria-errormessage=\"wpforms-44-field_61-postal-error\" required><label for=\"wpforms-44-field_61-postal\" class=\"wpforms-field-sublabel after\">Code postal<\/label><\/div><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-100\"><div id=\"wpforms-44-field_82-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_82\">Pays <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-44-field_82\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][82]\" placeholder=\"France\" aria-errormessage=\"wpforms-44-field_82-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_70-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_70\">\ud83e\udeaa ID S\u00e9curit\u00e9 Sociale <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"number\" id=\"wpforms-44-field_70\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][70]\" step=\"any\" aria-errormessage=\"wpforms-44-field_70-error\" aria-describedby=\"wpforms-44-field_70-description\" required><div id=\"wpforms-44-field_70-description\" class=\"wpforms-field-description\">\u2022 Nous utilisons votre num\u00e9ro de S\u00e9curit\u00e9 sociale uniquement pour l'inscrire sur l'arr\u00eat de travail.<\/div><\/div><div id=\"wpforms-44-field_36-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"36\"><div class=\"wpforms-clear wpforms-pagebreak-center\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4 last \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-44-field_108-container\" class=\"wpforms-field wpforms-field-payment-single\" data-field-id=\"108\"><label class=\"wpforms-field-label\">Prix <\/label><div class=\"wpforms-single-item-price-content\"><div class=\"wpforms-single-item-price wpforms-field-medium wpforms-payment-price\"> <span class=\"wpforms-price\">23,00 €<\/span><\/div><\/div><input type=\"hidden\" id=\"wpforms-44-field_108\" class=\"wpforms-field-medium wpforms-payment-price\" name=\"wpforms[fields][108]\" value=\"23,00 €\"><\/div><div id=\"wpforms-44-field_111-container\" class=\"wpforms-field wpforms-field-stripe-credit-card\" data-field-id=\"111\"><label class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">formulation neutre, administrative <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-no-columns wpforms-field-medium \" data-sublabel-position=\"above\" data-link-email=\"78\" data-required=\"1\"><div id=\"wpforms-field-stripe-payment-element-44\"><\/div><input type=\"text\" class=\"wpforms-stripe-credit-card-hidden-input\" name=\"wpforms[stripe-credit-card-hidden-input-44]\" disabled style=\"display: none;\"><\/div><div id=\"wpforms-44-field_111-description\" class=\"wpforms-field-description\">Service administratif \u2013 transmission de dossier au professionnel partenaire\n<\/div><\/div><div id=\"wpforms-44-field_5-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"5\"><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"44\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-44\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Terminer\" aria-live=\"assertive\" value=\"wpforms-submit\">Terminer<\/button><img decoding=\"async\" src=\"https:\/\/app.assistfranceonline.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Chargement en cours\"><\/div><\/form><\/div> ')) {\r\n console.log(\"\u26a0\ufe0f Shortcode WPForms d\u00e9tect\u00e9 en texte brut. Sous WordPress, il sera remplac\u00e9 automatiquement.\");\r\n }\r\n<\/script>\r\n<\/body>\r\n<\/html>\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>Assit France Online AssistFranceOnline T\u00c9L\u00c9CONSULTATION SANS RENDEZ-VOUS \u2013 7J\/7 Obtenez votre arr\u00eat maladie en ligne. Rapide, simple et s\u00e9curis\u00e9. Commander […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-9","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/comments?post=9"}],"version-history":[{"count":237,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\/revisions"}],"predecessor-version":[{"id":602,"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/pages\/9\/revisions\/602"}],"wp:attachment":[{"href":"https:\/\/app.assistfranceonline.com\/index.php\/wp-json\/wp\/v2\/media?parent=9"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}