{"id":47,"date":"2025-11-13T17:40:50","date_gmt":"2025-11-13T16:40:50","guid":{"rendered":"https:\/\/medaco-france.com\/?page_id=47"},"modified":"2026-03-23T14:02:54","modified_gmt":"2026-03-23T13:02:54","slug":"formulaire","status":"publish","type":"page","link":"https:\/\/villio-med-france.com\/","title":{"rendered":"Formulaire"},"content":{"rendered":"\t\t
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\n\t\t\t\t\t\n\n\n \n \n DrEEM France - Demander un arr\u00eat maladie<\/title>\n <link rel=\"stylesheet\" href=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/font-awesome\/6.0.0\/css\/all.min.css\">\n <style>\n \/* === VARIABLES COULEURS === *\/\n :root {\n --primary-blue: #1a73e8;\n --dark-blue: #0d47a1;\n --light-blue: #e8f0fe;\n --accent-green: #34a853;\n --white: #ffffff;\n --text-dark: #333333;\n --gray-light: #f8f9fa;\n --border-color: #e0e0e0;\n }\n \n \/* === RESET & BASE === *\/\n * {\n margin: 0;\n padding: 0;\n box-sizing: border-box;\n }\n \n body {\n font-family: 'Segoe UI', Tahoma, Geneva, Verdana, sans-serif;\n line-height: 1.6;\n color: var(--text-dark);\n background: linear-gradient(135deg, var(--light-blue) 0%, #e3f2fd 100%);\n min-height: 100vh;\n }\n \n .container {\n max-width: 1200px;\n margin: 0 auto;\n padding: 0 20px;\n }\n \n \/* === HEADER === *\/\n header {\n background: var(--white);\n box-shadow: 0 2px 10px rgba(0,0,0,0.1);\n position: fixed;\n width: 100%;\n top: 0;\n z-index: 1000;\n }\n \n .nav-container {\n display: flex;\n justify-content: space-between;\n align-items: center;\n padding: 15px 0;\n }\n \n .logo {\n font-size: 1.8rem;\n font-weight: 700;\n color: var(--primary-blue);\n text-decoration: none;\n }\n \n .nav-links {\n display: flex;\n list-style: none;\n gap: 30px;\n }\n \n .nav-links a {\n text-decoration: none;\n color: var(--text-dark);\n font-weight: 500;\n transition: color 0.3s;\n }\n \n .nav-links a:hover {\n color: var(--primary-blue);\n }\n \n \/* === MAIN CONTENT === *\/\n .main-content {\n padding: 120px 0 60px;\n }\n \n .form-container {\n display: grid;\n grid-template-columns: 1fr 1fr;\n gap: 60px;\n align-items: start;\n }\n \n \/* === FORM INFO SECTION === *\/\n .form-info {\n background: var(--white);\n padding: 50px 40px;\n border-radius: 20px;\n box-shadow: 0 15px 35px rgba(0,0,0,0.1);\n border-left: 5px solid var(--primary-blue);\n }\n \n .form-info h1 {\n font-size: 2.5rem;\n color: var(--dark-blue);\n margin-bottom: 20px;\n font-weight: 700;\n }\n \n .form-info p {\n font-size: 1.2rem;\n margin-bottom: 30px;\n color: var(--text-dark);\n opacity: 0.8;\n }\n \n .process-steps {\n margin: 40px 0;\n }\n \n .process-step {\n display: flex;\n align-items: flex-start;\n gap: 20px;\n margin-bottom: 30px;\n padding: 20px;\n background: var(--gray-light);\n border-radius: 10px;\n transition: transform 0.3s ease;\n }\n \n .process-step:hover {\n transform: translateX(10px);\n }\n \n .step-number {\n width: 40px;\n height: 40px;\n background: var(--primary-blue);\n color: var(--white);\n border-radius: 50%;\n display: flex;\n align-items: center;\n justify-content: center;\n font-weight: 700;\n flex-shrink: 0;\n }\n \n .step-content h3 {\n color: var(--dark-blue);\n margin-bottom: 8px;\n font-size: 1.2rem;\n }\n \n .guarantees {\n background: var(--light-blue);\n padding: 30px;\n border-radius: 15px;\n margin-top: 40px;\n }\n \n .guarantees h3 {\n color: var(--dark-blue);\n margin-bottom: 20px;\n font-size: 1.3rem;\n }\n \n .guarantee-list {\n list-style: none;\n }\n \n .guarantee-list li {\n display: flex;\n align-items: center;\n gap: 15px;\n margin-bottom: 15px;\n font-weight: 500;\n }\n \n .guarantee-list i {\n color: var(--accent-green);\n font-size: 1.2rem;\n }\n \n \/* === FORM SECTION === *\/\n .form-section {\n background: var(--white);\n padding: 50px 40px;\n border-radius: 20px;\n box-shadow: 0 15px 35px rgba(0,0,0,0.1);\n }\n \n .form-header {\n text-align: center;\n margin-bottom: 40px;\n }\n \n .form-header h2 {\n font-size: 2rem;\n color: var(--dark-blue);\n margin-bottom: 10px;\n }\n \n .form-header p {\n color: var(--text-dark);\n opacity: 0.7;\n }\n \n \/* === STYLING WPFORM === *\/\n .wpforms-container {\n max-width: 100% !important;\n }\n \n .wpforms-form input[type=\"text\"],\n .wpforms-form input[type=\"email\"],\n .wpforms-form input[type=\"tel\"],\n .wpforms-form textarea,\n .wpforms-form select {\n width: 100%;\n padding: 15px 20px;\n border: 2px solid var(--border-color);\n border-radius: 10px;\n font-size: 1rem;\n transition: all 0.3s ease;\n background: var(--white);\n }\n \n .wpforms-form input:focus,\n .wpforms-form textarea:focus,\n .wpforms-form select:focus {\n border-color: var(--primary-blue);\n box-shadow: 0 0 0 3px rgba(26, 115, 232, 0.1);\n outline: none;\n }\n \n .wpforms-form .wpforms-field-label {\n font-weight: 600;\n color: var(--dark-blue);\n margin-bottom: 8px;\n display: block;\n }\n \n .wpforms-form .wpforms-submit {\n background: var(--accent-green) !important;\n color: var(--white) !important;\n padding: 18px 40px !important;\n border: none !important;\n border-radius: 10px !important;\n font-size: 1.2rem !important;\n font-weight: 600 !important;\n width: 100%;\n transition: all 0.3s ease !important;\n cursor: pointer;\n }\n \n .wpforms-form .wpforms-submit:hover {\n background: #2e8b47 !important;\n transform: translateY(-2px);\n box-shadow: 0 10px 25px rgba(52, 168, 83, 0.3);\n }\n \n \/* === SECURITY BADGE === *\/\n .security-badge {\n text-align: center;\n margin-top: 30px;\n padding: 20px;\n background: var(--gray-light);\n border-radius: 10px;\n border: 2px solid var(--border-color);\n }\n \n .security-badge i {\n font-size: 2rem;\n color: var(--accent-green);\n margin-bottom: 10px;\n }\n \n .security-badge p {\n font-size: 0.9rem;\n color: var(--text-dark);\n opacity: 0.7;\n }\n \n \/* === SUPPORT SECTION === *\/\n .support-section {\n background: var(--white);\n padding: 40px;\n border-radius: 15px;\n margin-top: 40px;\n text-align: center;\n border: 2px dashed var(--border-color);\n }\n \n .support-section h3 {\n color: var(--dark-blue);\n margin-bottom: 15px;\n }\n \n .support-contact {\n display: flex;\n justify-content: center;\n gap: 30px;\n margin-top: 20px;\n flex-wrap: wrap;\n }\n \n .contact-item {\n display: flex;\n align-items: center;\n gap: 10px;\n color: var(--text-dark);\n text-decoration: none;\n transition: color 0.3s;\n }\n \n .contact-item:hover {\n color: var(--primary-blue);\n }\n \n \/* === RESPONSIVE === *\/\n @media (max-width: 968px) {\n .form-container {\n grid-template-columns: 1fr;\n gap: 40px;\n }\n \n .form-info,\n .form-section {\n padding: 40px 30px;\n }\n \n .form-info h1 {\n font-size: 2rem;\n }\n \n .nav-links {\n display: none;\n }\n \n .main-content {\n padding: 100px 0 40px;\n }\n }\n \n @media (max-width: 768px) {\n .support-contact {\n flex-direction: column;\n gap: 15px;\n }\n \n .process-step {\n padding: 15px;\n }\n }\n <\/style>\n<\/head>\n<body>\n\n <!-- HEADER -->\n \n\n <!-- MAIN CONTENT -->\n <div class=\"main-content\">\n <div class=\"container\">\n <div class=\"form-container\">\n <!-- LEFT COLUMN - INFORMATION -->\n <div class=\"form-info\">\n <h1>Demander votre arr\u00eat maladie en ligne<\/h1>\n <p>Remplissez ce formulaire pour consulter un m\u00e9decin et obtenir votre certificat m\u00e9dical sous 5 minutes.<\/p>\n \n <div class=\"process-steps\">\n <div class=\"process-step\">\n <div class=\"step-number\">1<\/div>\n <div class=\"step-content\">\n <h3>Formulaire s\u00e9curis\u00e9<\/h3>\n <p>Remplissez vos informations m\u00e9dicales en toute confidentialit\u00e9<\/p>\n <\/div>\n <\/div>\n \n <div class=\"process-step\">\n <div class=\"step-number\">2<\/div>\n <div class=\"step-content\">\n <h3>Consultation rapide<\/h3>\n <p>Un m\u00e9decin certifi\u00e9 \u00e9tudie votre demande sous 5 minutes<\/p>\n <\/div>\n <\/div>\n \n <div class=\"process-step\">\n <div class=\"step-number\">3<\/div>\n <div class=\"step-content\">\n <h3>Document imm\u00e9diat<\/h3>\n <p>Recevez votre arr\u00eat maladie par email, reconnu par les employeurs<\/p>\n <\/div>\n <\/div>\n <\/div>\n \n <div class=\"guarantees\">\n <h3>Vos garanties<\/h3>\n <ul class=\"guarantee-list\">\n <li>\n <i class=\"fas fa-shield-alt\"><\/i>\n <span>Donn\u00e9es m\u00e9dicales 100% confidentielles<\/span>\n <\/li>\n <li>\n <i class=\"fas fa-user-md\"><\/i>\n <span>M\u00e9decins dipl\u00f4m\u00e9s d'\u00c9tat<\/span>\n <\/li>\n <li>\n <i class=\"fas fa-clock\"><\/i>\n <span>Service disponible 24h\/24 et 7j\/7<\/span>\n <\/li>\n <li>\n <i class=\"fas fa-euro-sign\"><\/i>\n <span>Tarif transparent - Aucun frais cach\u00e9<\/span>\n <\/li>\n <\/ul>\n <\/div>\n <\/div>\n \n \n <!-- RIGHT COLUMN - FORMULAIRE -->\n <div class=\"form-section\">\n <div class=\"form-header\">\n <h2>Formulaire <\/h2>\n <p>Tous les champs marqu\u00e9s d'un * sont obligatoires<\/p>\n <\/div>\n \n <!-- REMPLACEZ CE COMMENTAIRE PAR VOTRE WPFORM -->\n <div class=\"wpforms-container\">\n <!-- COLLEZ VOTRE CODE WPFORM ICI -->\n <style id=\"wpforms-css-vars-44\">\n\t\t\t\t#wpforms-44 {\n\t\t\t\t--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: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-paypal-commerce 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\/47\" data-token=\"f7176bf5ff2f789c22b03cb78c26eeee\" data-token-time=\"1775372500\"><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 progress\" data-indicator=\"progress\" data-indicator-color=\"#3a54b3\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"22\" tabindex=\"-1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 22<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:4.5454545454545%;background-color:#3a54b3\"><\/div><\/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_13-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"13\"><div id=\"wpforms-44-field_13\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-44-field_13-error\"><h4 class=\"jfWelcome-header form-header\"><span style=\"color:#0000ff\">Bienvenue sur votre auto-diagnostic<\/span><\/h4>\n<div class=\"jfWelcome-description form-subHeader\"><span style=\"color:#3366ff\">Lors de votre auto-diagnostic, votre cas est imm\u00e9diatement transmis \u00e0 nos m\u00e9decins partenaires pour une v\u00e9rification en direct, permettant ainsi d'obtenir votre arr\u00eat maladie rapidement.<\/span><\/div>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-44-field_3-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"3\"><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\">Commencer<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 \" data-page=\"2\" style=\"display:none;\"><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\">Choisissez la maladie pr\u00e9sum\u00e9e: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-44-field_14\" class=\"wpforms-field-large wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-large\" data-search-enabled=\"1\" name=\"wpforms[fields][14]\" required=\"required\"><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=\"Le corps n\u2019est pas libre de ses mouvements\" class=\"choice-13 depth-1\" >Le corps n\u2019est pas libre de ses mouvements<\/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=\"\u00c9v\u00e8nement : Deuil, crise etc.\" class=\"choice-19 depth-1\" >\u00c9v\u00e8nement : Deuil, crise etc.<\/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_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=\"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_15-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"15\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-100\"><div class=\"wpforms-layout-column wpforms-layout-column-100\" ><div id=\"wpforms-44-field_16-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"16\"><fieldset><legend class=\"wpforms-field-label\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9 pour ce sympt\u00f4me par un m\u00e9decin ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_16\" class=\"wpforms-field-required\" data-choice-limit=\"1\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_16_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Oui\" aria-errormessage=\"wpforms-44-field_16_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_16_2\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Non\" aria-errormessage=\"wpforms-44-field_16_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_2\">Non<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_16_3\" data-rule-check-limit=\"true\" name=\"wpforms[fields][16][]\" value=\"Peut-etre\" aria-errormessage=\"wpforms-44-field_16_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_16_3\">Peut-etre<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_6-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"6\"><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 \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-44-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-3-columns\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">\ud83e\udd15 Choisissez vos sympt\u00f4mes : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Fi\u00e8vre\" aria-errormessage=\"wpforms-44-field_17_1-error\" required ><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\" name=\"wpforms[fields][17][]\" value=\"Naus\u00e9es\" aria-errormessage=\"wpforms-44-field_17_2-error\" required ><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\" name=\"wpforms[fields][17][]\" value=\"Diarrh\u00e9e\" aria-errormessage=\"wpforms-44-field_17_3-error\" required ><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\" name=\"wpforms[fields][17][]\" value=\"Toux sans mucus\" aria-errormessage=\"wpforms-44-field_17_4-error\" required ><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\" name=\"wpforms[fields][17][]\" value=\"Toux avec mucosit\u00e9s\" aria-errormessage=\"wpforms-44-field_17_5-error\" required ><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\" name=\"wpforms[fields][17][]\" value=\"Malaise\" aria-errormessage=\"wpforms-44-field_17_6-error\" required ><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\" name=\"wpforms[fields][17][]\" value=\"Fatigue\" aria-errormessage=\"wpforms-44-field_17_7-error\" required ><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\" name=\"wpforms[fields][17][]\" value=\"Hypertension art\u00e9rielle\" aria-errormessage=\"wpforms-44-field_17_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_9\">Hypertension art\u00e9rielle<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_8\" name=\"wpforms[fields][17][]\" value=\"Le corps n'est pas libre de ses mouvements\" aria-errormessage=\"wpforms-44-field_17_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_8\">Le corps n'est pas libre de ses mouvements<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_10\" name=\"wpforms[fields][17][]\" value=\"\u00c9v\u00e9nement stressant de la vie\" aria-errormessage=\"wpforms-44-field_17_10-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_17_10\">\u00c9v\u00e9nement stressant de la vie<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_17_11\" name=\"wpforms[fields][17][]\" value=\"Troubles du sommeil\" aria-errormessage=\"wpforms-44-field_17_11-error\" required ><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_7-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"7\"><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=\"4\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5 \" data-page=\"5\" style=\"display:none;\"><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\">douleurs situ\u00e9es dans la : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_24_1\" name=\"wpforms[fields][24][]\" value=\"T\u00eate\" aria-errormessage=\"wpforms-44-field_24_1-error\" required ><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\" name=\"wpforms[fields][24][]\" value=\"Ventre\" aria-errormessage=\"wpforms-44-field_24_2-error\" required ><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\" name=\"wpforms[fields][24][]\" value=\"Dent\" aria-errormessage=\"wpforms-44-field_24_3-error\" required ><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\" name=\"wpforms[fields][24][]\" value=\"Dos\" aria-errormessage=\"wpforms-44-field_24_4-error\" required ><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\" name=\"wpforms[fields][24][]\" value=\"Cou\" aria-errormessage=\"wpforms-44-field_24_7-error\" required ><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\" name=\"wpforms[fields][24][]\" value=\"Membres\" aria-errormessage=\"wpforms-44-field_24_6-error\" required ><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\" name=\"wpforms[fields][24][]\" value=\"Oreille\" aria-errormessage=\"wpforms-44-field_24_5-error\" required ><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\" name=\"wpforms[fields][24][]\" value=\"Organe sexuel\" aria-errormessage=\"wpforms-44-field_24_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_24_8\">Organe sexuel<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_23-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"23\"><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=\"5\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6 \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-44-field_26-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_26\">\ud83d\udcdd D\u00e9crire tous les autres sympt\u00f4mes :<\/label><textarea id=\"wpforms-44-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-44-field_26-error\" ><\/textarea><\/div><div id=\"wpforms-44-field_25-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"25\"><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=\"6\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7 \" data-page=\"7\" style=\"display:none;\"><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\">\u26a1 Est-ce que les sympt\u00f4mes sont apparues soudainement ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_27\" class=\"wpforms-field-required\" 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\" required ><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\" required ><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\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_27_3\">Peut-\u00eatre<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_28-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"28\"><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=\"7\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-8 \" data-page=\"8\" style=\"display:none;\"><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 Si vous prenez des m\u00e9dicaments : Quels sont les m\u00e9dicaments pris r\u00e9guli\u00e8rement ?<\/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_29-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"29\"><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=\"8\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-9 \" data-page=\"9\" style=\"display:none;\"><div id=\"wpforms-44-field_33-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"33\"><div id=\"wpforms-44-field_33\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-44-field_33-error\"><p>\u26a0\ufe0f Pr\u00e9sentez-vous l'un de ces facteurs de risque ?<\/p>\n<ul>\n<li><span style=\"color:#3366ff\">Vous avez des difficult\u00e9s respiratoires, des vomissements ou de la diarrh\u00e9e<\/span><\/li>\n<li><span style=\"color:#3366ff\">Bruits ou obstructions lors de la respiration<\/span><\/li>\n<li><span style=\"color:#3366ff\">Enceinte, immunod\u00e9ficience<\/span><\/li>\n<li><span style=\"color:#3366ff\">Douleur intense, en particulier dans l'oreille, le visage ou les membres<\/span><\/li>\n<li><span style=\"color:#3366ff\">Douleur au larynx, \u00e0 la poitrine ou \u00e0 l'abdomen<\/span><\/li>\n<li><span style=\"color:#3366ff\">Maladie cardiaque, respiratoire ou intestinale chronique<\/span><\/li>\n<li><span style=\"color:#3366ff\">Voyage tropical au cours des deux derniers mois<\/span><\/li>\n<li><span style=\"color:#3366ff\">Sentiment de maladie grave ou difficult\u00e9 \u00e0 avaler<\/span><\/li>\n<li><span style=\"color:#3366ff\">Paralysie, troubles de la conscience, saignements, \u00e9ruptions cutan\u00e9es<\/span><\/li>\n<\/ul>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-44-field_31-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">\u26a0\ufe0f Pr\u00e9sentez-vous l'un de ces facteurs de risque ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_31\" class=\"wpforms-field-required\" 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\" required ><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\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_31_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_34-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"34\"><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=\"9\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-10 \" data-page=\"10\" style=\"display:none;\"><div id=\"wpforms-44-field_93-container\" class=\"wpforms-field wpforms-field-content wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"93\" style=\"display:none;\"><div id=\"wpforms-44-field_93\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-44-field_93-error\"><h4>Votre cas ne peux pas \u00eatre traiter en ligne sans consultation d'un m\u00e9decin !<\/h4>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-44-field_90-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"90\"><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=\"10\" 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=\"10\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-11 \" data-page=\"11\" style=\"display:none;\"><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, m\u00e9fiant ou a d\u00e9j\u00e0 contest\u00e9 des attestations ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_35\" class=\"wpforms-field-required\" 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\" required ><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\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_35_2\">Non<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_39-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"39\"><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=\"11\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-12 \" data-page=\"12\" 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\">\ud83d\udcdd Avez-vous besoin d'un nouvel arr\u00eat maladie ou d'une prolongation ? <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\"><input type=\"checkbox\" id=\"wpforms-44-field_37_1\" data-rule-check-limit=\"true\" name=\"wpforms[fields][37][]\" value=\"Nouvel Arr\u00eat maladie\" aria-errormessage=\"wpforms-44-field_37_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_1\">Nouvel Arr\u00eat maladie<\/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=\"Suivi\" aria-errormessage=\"wpforms-44-field_37_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_37_2\">Suivi<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_38-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"38\"><div id=\"wpforms-44-field_38\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-44-field_38-error\"><p><span style=\"color:#3366ff\">Choisissez le suivi de l'arr\u00eat maladie uniquement si vous avez d\u00e9j\u00e0 eu un arr\u00eat maladie pour les m\u00eames sympt\u00f4mes et pour un maximum de 7 jours<\/span><\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/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-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"12\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-13 \" data-page=\"13\" style=\"display:none;\"><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\udc68\u200d\ud83d\udd27 Quelle est votre profession actuelle ? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-44-field_41\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][41]\" aria-errormessage=\"wpforms-44-field_41-error\" required><\/textarea><\/div><div id=\"wpforms-44-field_42-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"42\"><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=\"13\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-14 \" data-page=\"14\" style=\"display:none;\"><div id=\"wpforms-44-field_46-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"46\"><fieldset><legend class=\"wpforms-field-label\">\ud83d\udcaa \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_45-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"45\"><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=\"14\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-15 \" data-page=\"15\" style=\"display:none;\"><div id=\"wpforms-44-field_47-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"47\"><div id=\"wpforms-44-field_47\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-44-field_47-error\"><h4><img decoding=\"async\" class=\"emoji\" src=\"https:\/\/s.w.org\/images\/core\/emoji\/15.0.3\/svg\/1f4c6.svg\" alt=\"\ud83d\udcc6\" \/>\u00a0Choisissez les dates de d\u00e9but & de fin de votre incapacit\u00e9 de travail :<\/h4>\n<p>C'est-\u00e0-dire qu'en raison de la maladie, vous ne pouvez plus exercer votre m\u00e9tier ou vous pr\u00e9sentez un risque de retarder la gu\u00e9rison.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-44-field_48-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"48\"><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\">Date de 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\" 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 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\">Date de 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_43-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"43\"><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=\"15\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-16 \" data-page=\"16\" style=\"display:none;\"><div id=\"wpforms-44-field_52-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"52\"><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\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_53\">Pr\u00e9nom: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-44-field_53\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-44-field_53-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-44-field_54-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_54\">Nom : <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-44-field_54\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][54]\" aria-errormessage=\"wpforms-44-field_54-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 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\">T\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=\"T\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_78-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_78\">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_44-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"44\"><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=\"16\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-17 \" data-page=\"17\" style=\"display:none;\"><div id=\"wpforms-44-field_51-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"51\"><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_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=\"17\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-18 \" data-page=\"18\" style=\"display:none;\"><div id=\"wpforms-44-field_64-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"64\"><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_75-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_75\">Localisation du m\u00e9decin: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-44-field_75\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][75]\" aria-errormessage=\"wpforms-44-field_75-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_62-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"62\"><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=\"18\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-19 \" data-page=\"19\" style=\"display:none;\"><div id=\"wpforms-44-field_68-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"68\"><fieldset><legend class=\"wpforms-field-label\">Cochez la case appropri\u00e9e: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-44-field_68\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_68_1\" name=\"wpforms[fields][68][]\" value=\"Employ\u00e9\" aria-errormessage=\"wpforms-44-field_68_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_68_1\">Employ\u00e9<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_68_2\" name=\"wpforms[fields][68][]\" value=\"Ind\u00e9pendant\" aria-errormessage=\"wpforms-44-field_68_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_68_2\">Ind\u00e9pendant<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_68_3\" name=\"wpforms[fields][68][]\" value=\"Fonctionnaire\" aria-errormessage=\"wpforms-44-field_68_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_68_3\">Fonctionnaire<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_68_4\" name=\"wpforms[fields][68][]\" value=\"Activit\u00e9 non salari\u00e9 agricole\" aria-errormessage=\"wpforms-44-field_68_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_68_4\">Activit\u00e9 non salari\u00e9 agricole<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_68_5\" name=\"wpforms[fields][68][]\" value=\"\u00c9tudiant\" aria-errormessage=\"wpforms-44-field_68_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_68_5\">\u00c9tudiant<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-44-field_68_7\" name=\"wpforms[fields][68][]\" value=\"Sans emploi\" aria-errormessage=\"wpforms-44-field_68_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-44-field_68_7\">Sans emploi<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-44-field_67-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"67\"><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=\"19\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-20 \" data-page=\"20\" style=\"display:none;\"><div id=\"wpforms-44-field_69-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"69\"><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_70-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-44-field_70\">Num\u00e9ro de 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-medium wpforms-field-required\" name=\"wpforms[fields][70]\" step=\"any\" aria-errormessage=\"wpforms-44-field_70-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_66-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"66\"><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=\"20\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-21 \" data-page=\"21\" style=\"display:none;\"><div id=\"wpforms-44-field_74-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"74\"><div id=\"wpforms-44-field_74\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-44-field_74-error\"><h4><span class=\"jsQuestionLabelContainer jfQuestionLabelContainer\"><strong>Paiement s\u00e9curis\u00e9 de votre arr\u00eat maladie<\/strong><\/span><span class=\"jfRequiredStar\">*<\/span><\/h4>\n<h6><span style=\"font-family:monospace;font-size:16px\">Votre auto-diagnostic est d\u00e9j\u00e0 transmis \u00e0 l'un de nos m\u00e9decins partenaires<\/span><span style=\"font-family:monospace;font-size:16px\">,<\/span><\/h6>\n<p>vous recevrez votre arr\u00eat maladie tr\u00e8s rapidement<\/p>\n<div class=\"paymentCard-footer-wrapper\">\n<div class=\"paymentCard-productListWrapper\">\n<div class=\"paymentCard-footer\">\n<div class=\"paymentCard-footerRight new-payment-coupon\"><\/div>\n<\/div>\n<\/div>\n<\/div>\n<p>.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-44-field_122-container\" class=\"wpforms-field wpforms-field-payment-single\" data-field-id=\"122\"><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\">Prix\u00a0: <span class=\"wpforms-price\">24,00 €<\/span><\/div><\/div><input type=\"hidden\" id=\"wpforms-44-field_122\" class=\"wpforms-field-medium wpforms-payment-price\" name=\"wpforms[fields][122]\" value=\"24,00 €\"><\/div><div id=\"wpforms-44-field_120-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"120\"><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=\"21\" data-formid=\"44\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Suivant<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-22 last \" data-page=\"22\" style=\"display:none;\"><div id=\"wpforms-44-field_121-container\" class=\"wpforms-field wpforms-field-paypal-commerce\" data-field-id=\"121\"><label class=\"wpforms-field-label\">Paiement <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"hidden\" name=\"wpforms[fields][121][orderID]\" class=\"wpforms-paypal-commerce-order-id\" \/><input type=\"hidden\" name=\"wpforms[fields][121][subscriptionID]\" class=\"wpforms-paypal-commerce-subscription-id\" \/><input type=\"hidden\" name=\"wpforms[fields][121][source]\" class=\"wpforms-paypal-commerce-source\" \/><div class=\"wpforms-paypal-commerce-card-fields \"><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-paypal-commerce-supported-cards\"><div class=\"wpforms-paypal-commerce-mastercard-icon\"><\/div><div class=\"wpforms-paypal-commerce-visa-icon\"><\/div><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-paypal-commerce-number\"><div id=\"wpforms-44-field_121-cardnumber\" class=\"wpforms-field-paypal-commerce-cardnumber wpforms-field-required\" aria-errormessage=\"wpforms-44-field_121-cardnumber-error\" data-required=\"required\"><\/div><input type=\"text\" class=\"wpforms-paypal-commerce-credit-card-hidden-input\" name=\"wpforms[paypal-commerce-credit-card-hidden-input-44]\" id=\"wpforms-paypal-commerce-credit-card-hidden-input-44-number\" disabled style=\"display: none;\"><label for=\"wpforms-paypal-commerce-credit-card-hidden-input-44-number\" class=\"wpforms-field-sublabel after\">Num\u00e9ro de carte<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-row-responsive wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first wpforms-field-paypal-commerce-date\"><div id=\"wpforms-44-field_121-carddate\" class=\"wpforms-field-paypal-commerce-carddate wpforms-field-required\" aria-errormessage=\"wpforms-44-field_121-carddate-error\" data-required=\"required\"><\/div><input type=\"text\" class=\"wpforms-paypal-commerce-credit-card-hidden-input\" name=\"wpforms[paypal-commerce-credit-card-hidden-input-44]\" id=\"wpforms-paypal-commerce-credit-card-hidden-input-44-date\" disabled style=\"display: none;\"><label for=\"wpforms-paypal-commerce-credit-card-hidden-input-44-date\" class=\"wpforms-field-sublabel after\">Date d\u2019expiration<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half wpforms-field-paypal-commerce-code\"><div id=\"wpforms-44-field_121-cardcode\" class=\"wpforms-field-paypal-commerce-cardcode wpforms-field-required\" aria-errormessage=\"wpforms-44-field_121-cardcode-error\" data-required=\"required\"><\/div><input type=\"text\" class=\"wpforms-paypal-commerce-credit-card-hidden-input\" name=\"wpforms[paypal-commerce-credit-card-hidden-input-44]\" id=\"wpforms-paypal-commerce-credit-card-hidden-input-44-code\" disabled style=\"display: none;\"><label for=\"wpforms-paypal-commerce-credit-card-hidden-input-44-code\" class=\"wpforms-field-sublabel after\">Code de s\u00e9curit\u00e9 (CVC)<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-paypal-commerce-name\"><input type=\"text\" id=\"wpforms-44-field_121-cardname\" class=\"wpforms-field-paypal-commerce-cardname wpforms-field-required\" name=\"wpforms[fields][121][cardname]\" aria-errormessage=\"wpforms-44-field_121-cardname-error\" required><label for=\"wpforms-44-field_121-cardname\" class=\"wpforms-field-sublabel after\">Nom du titulaire de la carte<\/label><\/div><\/div><\/div><\/div><div id=\"wpforms-44-field_5-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"5\"><\/div><\/div><\/div><!-- .wpforms-field-container --><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:\/\/villio-med-france.com\/index.php\/wp-json\/wp\/v2\/pages\/47\"><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:\/\/villio-med-france.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" 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