mon.aphp.fr
Open in
urlscan Pro
164.2.244.105
Public Scan
URL:
https://mon.aphp.fr/preadmission
Submission: On May 07 via manual from FR — Scanned from FR
Submission: On May 07 via manual from FR — Scanned from FR
Form analysis 1 forms found in the DOM
<form class="form">
<div class="block">
<div class="block-form">
<div class="justify-content-md-center row">
<div class="col"><span>Vous êtes déjà patient de l’AP-HP ? Utilisez FranceConnect pour générer votre attestation de droits d’Assurance maladie automatiquement.</span></div>
<div class="col-md-auto"><a href="https://mon.aphp.fr/be/security/authorize/fc"><img class="fc-button-image" alt="France Connect" src="/3c0f9f160c390ee266ce082cc1c8f61a.svg"></a></div>
</div>
</div>
</div>
<div class="block">
<h2>Dossier administratif</h2>
<div class="block-form">
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="context-iep" class="">IEP (facultatif)<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve" width="512px"
height="512px" class="tooltip-image" id="iepTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label><input name="context.iep" id="context-iep" placeholder="_ _ _ _ _ _ _" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback"></div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<fieldset class="radio-group prepareBox form-group">
<legend>Je prépare :</legend>
<div>
<div class="form-check"><input name="context.forWhom" id="context-forWhom-0" type="radio" class="form-check-input" aria-invalid="false" value="me"><label for="context-forWhom-0" class="center-items radio form-check-label">mon
dossier</label></div>
<div class="form-check"><input name="context.forWhom" id="context-forWhom-1" type="radio" class="form-check-input" aria-invalid="false" value="notMe"><label for="context-forWhom-1" class="center-items radio form-check-label">le dossier
d'un patient mineur ou majeur protégé</label></div>
</div>
</fieldset>
</div>
<div class="col-md-6">
<fieldset class="radio-group form-group">
<legend>Pour :</legend>
<div>
<div class="form-check"><input name="context.forWhat" id="context-forWhat-0" type="radio" class="form-check-input" aria-invalid="false" value="teleconsultation"><label for="context-forWhat-0"
class="center-items radio form-check-label">préparer une téléconsultation</label></div>
<div class="form-check"><input name="context.forWhat" id="context-forWhat-1" type="radio" class="form-check-input" aria-invalid="false" value="consultation"><label for="context-forWhat-1"
class="center-items radio form-check-label">préparer une consultation</label></div>
<div class="form-check"><input name="context.forWhat" id="context-forWhat-2" type="radio" class="form-check-input" aria-invalid="false" value="hospitalization"><label for="context-forWhat-2"
class="center-items radio form-check-label">préparer une hospitalisation</label></div>
<div class="form-check"><input name="context.forWhat" id="context-forWhat-3" type="radio" class="form-check-input" aria-invalid="false" value="emergency"><label for="context-forWhat-3"
class="center-items radio form-check-label">régulariser un passage aux urgences ou une hospitalisation</label></div>
</div>
</fieldset>
</div>
</div>
</div>
</div>
<div class="block">
<h2>Lieu et date de prise en charge</h2>
<div class="block-form">
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="appointment-hospital" class="">Établissement<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve"
width="512px" height="512px" class="tooltip-image" id="hospitalTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label><select name="appointment.hospital" id="appointment-hospital" class="form-control" aria-invalid="false">
<option></option>
</select>
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
<div class="uhBox col-md-6">
<div class="form-group"><label for="appointment-uh" class="">UH (si connu)<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve" width="512px"
height="512px" class="tooltip-image" id="uhTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label><input name="appointment.uh" id="appointment-uh" placeholder="_ _ _" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback"></div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="appointment-service" class="">Service</label><input name="appointment.service" id="appointment-service" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback"></div>
</div>
</div>
<div class="col-md-6">
<div class="form-group"><label for="appointment-physician" class="">Médecin</label><input name="appointment.physician" id="appointment-physician" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback"></div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="appointment-date" class="label-inputGroup">Date<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve"
width="512px" height="512px" class="tooltip-image" id="dateTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label>
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 26 28" class="icon icon-date">
<path
d="M2 26h4.5v-4.5h-4.5v4.5zM7.5 26h5v-4.5h-5v4.5zM2 20.5h4.5v-5h-4.5v5zM7.5 20.5h5v-5h-5v5zM2 14.5h4.5v-4.5h-4.5v4.5zM13.5 26h5v-4.5h-5v4.5zM7.5 14.5h5v-4.5h-5v4.5zM19.5 26h4.5v-4.5h-4.5v4.5zM13.5 20.5h5v-5h-5v5zM8 7v-4.5c0-0.266-0.234-0.5-0.5-0.5h-1c-0.266 0-0.5 0.234-0.5 0.5v4.5c0 0.266 0.234 0.5 0.5 0.5h1c0.266 0 0.5-0.234 0.5-0.5zM19.5 20.5h4.5v-5h-4.5v5zM13.5 14.5h5v-4.5h-5v4.5zM19.5 14.5h4.5v-4.5h-4.5v4.5zM20 7v-4.5c0-0.266-0.234-0.5-0.5-0.5h-1c-0.266 0-0.5 0.234-0.5 0.5v4.5c0 0.266 0.234 0.5 0.5 0.5h1c0.266 0 0.5-0.234 0.5-0.5zM26 6v20c0 1.094-0.906 2-2 2h-22c-1.094 0-2-0.906-2-2v-20c0-1.094 0.906-2 2-2h2v-1.5c0-1.375 1.125-2.5 2.5-2.5h1c1.375 0 2.5 1.125 2.5 2.5v1.5h6v-1.5c0-1.375 1.125-2.5 2.5-2.5h1c1.375 0 2.5 1.125 2.5 2.5v1.5h2c1.094 0 2 0.906 2 2z">
</path>
</svg></div>
<div class="react-datepicker-wrapper">
<div class="react-datepicker__input-container"><input id="appointment-date" name="appointment.date" placeholder="jj/mm/aaaa" disabled="" autocomplete="none" aria-invalid="false" type="text" class="form-control form-control" value="">
</div>
</div><input type="hidden" class="form-control" aria-invalid="false">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block">
<h2>Identité et coordonnées du patient</h2>
<div class="block-form">
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-ipp" class="">IPP (si connu)<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve" width="512px"
height="512px" class="tooltip-image" id="ippTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label><input name="patient.ipp" id="patient-ipp" placeholder="80 _ _ _ _ _ _ _ _" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback"></div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-birthName" class="">Nom de naissance</label><input name="patient.birthName" id="patient-birthName" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group"><label for="patient-lastName" class="">Nom d'usage</label><input name="patient.lastName" id="patient-lastName" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback"></div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-firstName" class="">Prénom</label><input name="patient.firstName" id="patient-firstName" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
<div class="col-md-6">
<fieldset class="radio-group form-group">
<legend>Sexe</legend>
<div>
<div class="form-check form-check-inline"><input name="patient.gender" id="patient-gender-0" type="radio" class="form-check-input" aria-invalid="false" value="woman"><label for="patient-gender-0"
class="container-radio form-check-label">Femme</label></div>
<div class="form-check form-check-inline"><input name="patient.gender" id="patient-gender-1" type="radio" class="form-check-input" aria-invalid="false" value="man"><label for="patient-gender-1"
class="container-radio form-check-label">Homme</label></div>
</div>
</fieldset>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-birthDate" class="label-inputGroup">Date de naissance</label>
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 26 28" class="icon icon-date">
<path
d="M2 26h4.5v-4.5h-4.5v4.5zM7.5 26h5v-4.5h-5v4.5zM2 20.5h4.5v-5h-4.5v5zM7.5 20.5h5v-5h-5v5zM2 14.5h4.5v-4.5h-4.5v4.5zM13.5 26h5v-4.5h-5v4.5zM7.5 14.5h5v-4.5h-5v4.5zM19.5 26h4.5v-4.5h-4.5v4.5zM13.5 20.5h5v-5h-5v5zM8 7v-4.5c0-0.266-0.234-0.5-0.5-0.5h-1c-0.266 0-0.5 0.234-0.5 0.5v4.5c0 0.266 0.234 0.5 0.5 0.5h1c0.266 0 0.5-0.234 0.5-0.5zM19.5 20.5h4.5v-5h-4.5v5zM13.5 14.5h5v-4.5h-5v4.5zM19.5 14.5h4.5v-4.5h-4.5v4.5zM20 7v-4.5c0-0.266-0.234-0.5-0.5-0.5h-1c-0.266 0-0.5 0.234-0.5 0.5v4.5c0 0.266 0.234 0.5 0.5 0.5h1c0.266 0 0.5-0.234 0.5-0.5zM26 6v20c0 1.094-0.906 2-2 2h-22c-1.094 0-2-0.906-2-2v-20c0-1.094 0.906-2 2-2h2v-1.5c0-1.375 1.125-2.5 2.5-2.5h1c1.375 0 2.5 1.125 2.5 2.5v1.5h6v-1.5c0-1.375 1.125-2.5 2.5-2.5h1c1.375 0 2.5 1.125 2.5 2.5v1.5h2c1.094 0 2 0.906 2 2z">
</path>
</svg></div>
<div class="react-datepicker-wrapper">
<div class="react-datepicker__input-container"><input id="patient-birthDate" name="patient.birthDate" placeholder="jj/mm/aaaa" autocomplete="none" aria-invalid="false" type="text" class="form-control form-control" value=""></div>
</div><input type="hidden" class="form-control" aria-invalid="false">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-birthCountry" class="">Pays de naissance</label><select name="patient.birthCountry" id="patient-birthCountry" class="form-control" aria-invalid="false">
<option></option>
<option value="Afghanistan">Afghanistan</option>
<option value="Afrique du Sud">Afrique du Sud</option>
<option value="Albanie">Albanie</option>
<option value="Algérie">Algérie</option>
<option value="Allemagne">Allemagne</option>
<option value="Andorre">Andorre</option>
<option value="Angola">Angola</option>
<option value="Anguilla">Anguilla</option>
<option value="Antarctique">Antarctique</option>
<option value="Antigua-et-Barbuda">Antigua-et-Barbuda</option>
<option value="Antilles Néerlandaises">Antilles Néerlandaises</option>
<option value="Arabie Saoudite">Arabie Saoudite</option>
<option value="Argentine">Argentine</option>
<option value="Arménie">Arménie</option>
<option value="Aruba">Aruba</option>
<option value="Australie">Australie</option>
<option value="Autriche">Autriche</option>
<option value="Azerbaïdjan">Azerbaïdjan</option>
<option value="Bahamas">Bahamas</option>
<option value="Bahreïn">Bahreïn</option>
<option value="Bangladesh">Bangladesh</option>
<option value="Barbade">Barbade</option>
<option value="Bélarus">Bélarus</option>
<option value="Belgique">Belgique</option>
<option value="Belize">Belize</option>
<option value="Bénin">Bénin</option>
<option value="Bermudes">Bermudes</option>
<option value="Bhoutan">Bhoutan</option>
<option value="Bolivie">Bolivie</option>
<option value="Bosnie-Herzégovine">Bosnie-Herzégovine</option>
<option value="Botswana">Botswana</option>
<option value="Brésil">Brésil</option>
<option value="Brunéi Darussalam">Brunéi Darussalam</option>
<option value="Bulgarie">Bulgarie</option>
<option value="Burkina Faso">Burkina Faso</option>
<option value="Burundi">Burundi</option>
<option value="Cambodge">Cambodge</option>
<option value="Cameroun">Cameroun</option>
<option value="Canada">Canada</option>
<option value="Cap-vert">Cap-vert</option>
<option value="Chili">Chili</option>
<option value="Chine">Chine</option>
<option value="Chypre">Chypre</option>
<option value="Colombie">Colombie</option>
<option value="Comores">Comores</option>
<option value="Costa Rica">Costa Rica</option>
<option value="Côte d'Ivoire">Côte d'Ivoire</option>
<option value="Croatie">Croatie</option>
<option value="Cuba">Cuba</option>
<option value="Danemark">Danemark</option>
<option value="Djibouti">Djibouti</option>
<option value="Dominique">Dominique</option>
<option value="Égypte">Égypte</option>
<option value="El Salvador">El Salvador</option>
<option value="Émirats Arabes Unis">Émirats Arabes Unis</option>
<option value="Équateur">Équateur</option>
<option value="Érythrée">Érythrée</option>
<option value="Espagne">Espagne</option>
<option value="Estonie">Estonie</option>
<option value="États Fédérés de Micronésie">États Fédérés de Micronésie</option>
<option value="États-Unis">États-Unis</option>
<option value="Éthiopie">Éthiopie</option>
<option value="Fédération de Russie">Fédération de Russie</option>
<option value="Fidji">Fidji</option>
<option value="Finlande">Finlande</option>
<option value="France">France</option>
<option value="Gabon">Gabon</option>
<option value="Gambie">Gambie</option>
<option value="Géorgie">Géorgie</option>
<option value="Géorgie du Sud et les Îles Sandwich du Sud">Géorgie du Sud et les Îles Sandwich du Sud</option>
<option value="Ghana">Ghana</option>
<option value="Gibraltar">Gibraltar</option>
<option value="Grèce">Grèce</option>
<option value="Grenade">Grenade</option>
<option value="Groenland">Groenland</option>
<option value="Guadeloupe">Guadeloupe</option>
<option value="Guam">Guam</option>
<option value="Guatemala">Guatemala</option>
<option value="Guinée">Guinée</option>
<option value="Guinée-Bissau">Guinée-Bissau</option>
<option value="Guinée Équatoriale">Guinée Équatoriale</option>
<option value="Guyana">Guyana</option>
<option value="Guyane Française">Guyane Française</option>
<option value="Haïti">Haïti</option>
<option value="Honduras">Honduras</option>
<option value="Hong-Kong">Hong-Kong</option>
<option value="Hongrie">Hongrie</option>
<option value="Île Bouvet">Île Bouvet</option>
<option value="Île Christmas">Île Christmas</option>
<option value="Île de Man">Île de Man</option>
<option value="Île Norfolk">Île Norfolk</option>
<option value="Îles Åland">Îles Åland</option>
<option value="Îles Caïmanes">Îles Caïmanes</option>
<option value="Îles Cocos (Keeling)">Îles Cocos (Keeling)</option>
<option value="Îles Cook">Îles Cook</option>
<option value="Îles Féroé">Îles Féroé</option>
<option value="Îles Heard et Mcdonald">Îles Heard et Mcdonald</option>
<option value="Îles (malvinas) Falkland">Îles (malvinas) Falkland</option>
<option value="Îles Mariannes du Nord">Îles Mariannes du Nord</option>
<option value="Îles Marshall">Îles Marshall</option>
<option value="Îles Mineures Éloignées des États-Unis">Îles Mineures Éloignées des États-Unis</option>
<option value="Îles Salomon">Îles Salomon</option>
<option value="Îles Turks et Caïques">Îles Turks et Caïques</option>
<option value="Îles Vierges Britanniques">Îles Vierges Britanniques</option>
<option value="Îles Vierges des États-Unis">Îles Vierges des États-Unis</option>
<option value="Inde">Inde</option>
<option value="Indonésie">Indonésie</option>
<option value="Iraq">Iraq</option>
<option value="Irlande">Irlande</option>
<option value="Islande">Islande</option>
<option value="Israël">Israël</option>
<option value="Italie">Italie</option>
<option value="Jamahiriya Arabe Libyenne">Jamahiriya Arabe Libyenne</option>
<option value="Jamaïque">Jamaïque</option>
<option value="Japon">Japon</option>
<option value="Jordanie">Jordanie</option>
<option value="Kazakhstan">Kazakhstan</option>
<option value="Kenya">Kenya</option>
<option value="Kirghizistan">Kirghizistan</option>
<option value="Kiribati">Kiribati</option>
<option value="Koweït">Koweït</option>
<option value="Lesotho">Lesotho</option>
<option value="Lettonie">Lettonie</option>
<option value="L'ex-République Yougoslave de Macédoine">L'ex-République Yougoslave de Macédoine</option>
<option value="Liban">Liban</option>
<option value="Libéria">Libéria</option>
<option value="Liechtenstein">Liechtenstein</option>
<option value="Lituanie">Lituanie</option>
<option value="Luxembourg">Luxembourg</option>
<option value="Macao">Macao</option>
<option value="Madagascar">Madagascar</option>
<option value="Malaisie">Malaisie</option>
<option value="Malawi">Malawi</option>
<option value="Maldives">Maldives</option>
<option value="Mali">Mali</option>
<option value="Malte">Malte</option>
<option value="Maroc">Maroc</option>
<option value="Martinique">Martinique</option>
<option value="Maurice">Maurice</option>
<option value="Mauritanie">Mauritanie</option>
<option value="Mayotte">Mayotte</option>
<option value="Mexique">Mexique</option>
<option value="Monaco">Monaco</option>
<option value="Mongolie">Mongolie</option>
<option value="Montserrat">Montserrat</option>
<option value="Mozambique">Mozambique</option>
<option value="Myanmar">Myanmar</option>
<option value="Namibie">Namibie</option>
<option value="Nauru">Nauru</option>
<option value="Népal">Népal</option>
<option value="Nicaragua">Nicaragua</option>
<option value="Niger">Niger</option>
<option value="Nigéria">Nigéria</option>
<option value="Niué">Niué</option>
<option value="Norvège">Norvège</option>
<option value="Nouvelle-Calédonie">Nouvelle-Calédonie</option>
<option value="Nouvelle-Zélande">Nouvelle-Zélande</option>
<option value="Oman">Oman</option>
<option value="Ouganda">Ouganda</option>
<option value="Ouzbékistan">Ouzbékistan</option>
<option value="Pakistan">Pakistan</option>
<option value="Palaos">Palaos</option>
<option value="Panama">Panama</option>
<option value="Papouasie-Nouvelle-Guinée">Papouasie-Nouvelle-Guinée</option>
<option value="Paraguay">Paraguay</option>
<option value="Pays-Bas">Pays-Bas</option>
<option value="Pérou">Pérou</option>
<option value="Philippines">Philippines</option>
<option value="Pitcairn">Pitcairn</option>
<option value="Pologne">Pologne</option>
<option value="Polynésie Française">Polynésie Française</option>
<option value="Porto Rico">Porto Rico</option>
<option value="Portugal">Portugal</option>
<option value="Qatar">Qatar</option>
<option value="République Arabe Syrienne">République Arabe Syrienne</option>
<option value="République Centrafricaine">République Centrafricaine</option>
<option value="République de Corée">République de Corée</option>
<option value="République Démocratique du Congo">République Démocratique du Congo</option>
<option value="République Démocratique Populaire Lao">République Démocratique Populaire Lao</option>
<option value="République de Moldova">République de Moldova</option>
<option value="République Dominicaine">République Dominicaine</option>
<option value="République du Congo">République du Congo</option>
<option value="République Islamique d'Iran">République Islamique d'Iran</option>
<option value="République Populaire Démocratique de Corée">République Populaire Démocratique de Corée</option>
<option value="République Tchèque">République Tchèque</option>
<option value="République-Unie de Tanzanie">République-Unie de Tanzanie</option>
<option value="Réunion">Réunion</option>
<option value="Roumanie">Roumanie</option>
<option value="Royaume-Uni">Royaume-Uni</option>
<option value="Rwanda">Rwanda</option>
<option value="Sahara Occidental">Sahara Occidental</option>
<option value="Sainte-Hélène">Sainte-Hélène</option>
<option value="Sainte-Lucie">Sainte-Lucie</option>
<option value="Saint-Kitts-et-Nevis">Saint-Kitts-et-Nevis</option>
<option value="Saint-Marin">Saint-Marin</option>
<option value="Saint-Pierre-et-Miquelon">Saint-Pierre-et-Miquelon</option>
<option value="Saint-Siège (état de la Cité du Vatican)">Saint-Siège (état de la Cité du Vatican)</option>
<option value="Saint-Vincent-et-les Grenadines">Saint-Vincent-et-les Grenadines</option>
<option value="Samoa">Samoa</option>
<option value="Samoa Américaines">Samoa Américaines</option>
<option value="Sao Tomé-et-Principe">Sao Tomé-et-Principe</option>
<option value="Sénégal">Sénégal</option>
<option value="Serbie-et-Monténégro">Serbie-et-Monténégro</option>
<option value="Seychelles">Seychelles</option>
<option value="Sierra Leone">Sierra Leone</option>
<option value="Singapour">Singapour</option>
<option value="Slovaquie">Slovaquie</option>
<option value="Slovénie">Slovénie</option>
<option value="Somalie">Somalie</option>
<option value="Soudan">Soudan</option>
<option value="Sri Lanka">Sri Lanka</option>
<option value="Suède">Suède</option>
<option value="Suisse">Suisse</option>
<option value="Suriname">Suriname</option>
<option value="Svalbard etÎle Jan Mayen">Svalbard etÎle Jan Mayen</option>
<option value="Swaziland">Swaziland</option>
<option value="Tadjikistan">Tadjikistan</option>
<option value="Taïwan">Taïwan</option>
<option value="Tchad">Tchad</option>
<option value="Terres Australes Françaises">Terres Australes Françaises</option>
<option value="Territoire Britannique de l'Océan Indien">Territoire Britannique de l'Océan Indien</option>
<option value="Territoire Palestinien Occupé">Territoire Palestinien Occupé</option>
<option value="Thaïlande">Thaïlande</option>
<option value="Timor-Leste">Timor-Leste</option>
<option value="Togo">Togo</option>
<option value="Tokelau">Tokelau</option>
<option value="Tonga">Tonga</option>
<option value="Trinité-et-Tobago">Trinité-et-Tobago</option>
<option value="Tunisie">Tunisie</option>
<option value="Turkménistan">Turkménistan</option>
<option value="Turquie">Turquie</option>
<option value="Tuvalu">Tuvalu</option>
<option value="Ukraine">Ukraine</option>
<option value="Uruguay">Uruguay</option>
<option value="Vanuatu">Vanuatu</option>
<option value="Venezuela">Venezuela</option>
<option value="Viet Nam">Viet Nam</option>
<option value="Wallis et Futuna">Wallis et Futuna</option>
<option value="Yémen">Yémen</option>
<option value="Zambie">Zambie</option>
<option value="Zimbabwe">Zimbabwe</option>
</select>
<div class="invalid-feedback"></div>
</div>
</div>
<div class="col-md-6">
<div class="form-group"><label for="patient-birthTown" class="">Ville de naissance</label><input name="patient.birthTown" id="patient-birthTown" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
</div>
<h2 class="sepTitle">Adresses et justificatifs du patient</h2>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-identityAttachmentType" class="">Pièce d'identité</label><select name="patient.identityAttachmentType" id="patient-identityAttachmentType" class="form-control" aria-invalid="false">
<option></option>
<option value="1">Carte d'identité</option>
<option value="2">Passeport</option>
<option value="3">Titre de séjour</option>
</select>
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
<div class="uploadBox col-md-6">
<div class="form-group"><label for="patient-identityAttachmentFile" class="">Pièce jointe (uniquement recto demandé)<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px"
viewBox="0 0 23.625 23.625" xml:space="preserve" width="512px" height="512px" class="tooltip-image" id="identityAttachmentFileTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label>
<section>
<div role="button" tabindex="0" class="fileInputBox">
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 26 28" class="icon icon-dl">
<path
d="M20 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM24 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM26 19.5v5c0 0.828-0.672 1.5-1.5 1.5h-23c-0.828 0-1.5-0.672-1.5-1.5v-5c0-0.828 0.672-1.5 1.5-1.5h6.672c0.422 1.156 1.531 2 2.828 2h4c1.297 0 2.406-0.844 2.828-2h6.672c0.828 0 1.5 0.672 1.5 1.5zM20.922 9.375c-0.156 0.375-0.516 0.625-0.922 0.625h-4v7c0 0.547-0.453 1-1 1h-4c-0.547 0-1-0.453-1-1v-7h-4c-0.406 0-0.766-0.25-0.922-0.625-0.156-0.359-0.078-0.797 0.219-1.078l7-7c0.187-0.203 0.453-0.297 0.703-0.297s0.516 0.094 0.703 0.297l7 7c0.297 0.281 0.375 0.719 0.219 1.078z">
</path>
</svg></div><input accept="application/pdf,image/bmp,image/gif,image/jpeg,image/png,image/tiff" type="file" autocomplete="off" tabindex="-1" style="display: none;"><input name="patient.identityAttachmentFile"
id="patient-identityAttachmentFile" placeholder="Cliquer ou déposer un fichier" type="text" class="cursor-pointer form-control" aria-invalid="false" value="">
</div>
</div>
</section>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-phone" class="label-inputGroup">Numéro de téléphone</label>
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 12 28" class="icon icon-tel">
<path
d="M7.25 22c0-0.688-0.562-1.25-1.25-1.25s-1.25 0.562-1.25 1.25 0.562 1.25 1.25 1.25 1.25-0.562 1.25-1.25zM10.5 19.5v-11c0-0.266-0.234-0.5-0.5-0.5h-8c-0.266 0-0.5 0.234-0.5 0.5v11c0 0.266 0.234 0.5 0.5 0.5h8c0.266 0 0.5-0.234 0.5-0.5zM7.5 6.25c0-0.141-0.109-0.25-0.25-0.25h-2.5c-0.141 0-0.25 0.109-0.25 0.25s0.109 0.25 0.25 0.25h2.5c0.141 0 0.25-0.109 0.25-0.25zM12 6v16c0 1.094-0.906 2-2 2h-8c-1.094 0-2-0.906-2-2v-16c0-1.094 0.906-2 2-2h8c1.094 0 2 0.906 2 2z">
</path>
</svg></div><input name="patient.phone" id="patient-phone" type="tel" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group"><label for="patient-email" class="label-inputGroup">Adresse e-mail</label>
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 28 28" class="icon icon-mail">
<path
d="M26 23.5v-12c-0.328 0.375-0.688 0.719-1.078 1.031-2.234 1.719-4.484 3.469-6.656 5.281-1.172 0.984-2.625 2.188-4.25 2.188h-0.031c-1.625 0-3.078-1.203-4.25-2.188-2.172-1.813-4.422-3.563-6.656-5.281-0.391-0.313-0.75-0.656-1.078-1.031v12c0 0.266 0.234 0.5 0.5 0.5h23c0.266 0 0.5-0.234 0.5-0.5zM26 7.078c0-0.391 0.094-1.078-0.5-1.078h-23c-0.266 0-0.5 0.234-0.5 0.5 0 1.781 0.891 3.328 2.297 4.438 2.094 1.641 4.188 3.297 6.266 4.953 0.828 0.672 2.328 2.109 3.422 2.109h0.031c1.094 0 2.594-1.437 3.422-2.109 2.078-1.656 4.172-3.313 6.266-4.953 1.016-0.797 2.297-2.531 2.297-3.859zM28 6.5v17c0 1.375-1.125 2.5-2.5 2.5h-23c-1.375 0-2.5-1.125-2.5-2.5v-17c0-1.375 1.125-2.5 2.5-2.5h23c1.375 0 2.5 1.125 2.5 2.5z">
</path>
</svg></div><input name="patient.email" id="patient-email" type="email" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
</div>
</div>
<div class="form-group"><label for="patient-address" class="">Adresse principale</label><textarea name="patient.address" id="patient-address" autocomplete="none" class="form-control" aria-invalid="false"></textarea>
<div class="invalid-feedback">Ce champ est requis.</div>
<ul class="list-group"></ul>
</div>
<div hidden="" class="row">
<div class="col-md-6">
<div class="form-group"><label for="patient-addressAttachmentType" class="">Justificatif de domicile</label><select name="patient.addressAttachmentType" id="patient-addressAttachmentType" class="form-control" aria-invalid="false">
<option></option>
<option value="7">Facture d'électricité ou de gaz</option>
<option value="8">Taxe d'habitation ou foncière</option>
</select>
<div class="invalid-feedback"></div>
</div>
</div>
<div class="uploadBox col-md-6">
<div class="form-group"><label for="patient-addressAttachmentFile" class="">Pièce jointe<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve"
width="512px" height="512px" class="tooltip-image" id="addressAttachmentFileTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label>
<section>
<div role="button" tabindex="0" class="fileInputBox">
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 26 28" class="icon icon-dl">
<path
d="M20 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM24 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM26 19.5v5c0 0.828-0.672 1.5-1.5 1.5h-23c-0.828 0-1.5-0.672-1.5-1.5v-5c0-0.828 0.672-1.5 1.5-1.5h6.672c0.422 1.156 1.531 2 2.828 2h4c1.297 0 2.406-0.844 2.828-2h6.672c0.828 0 1.5 0.672 1.5 1.5zM20.922 9.375c-0.156 0.375-0.516 0.625-0.922 0.625h-4v7c0 0.547-0.453 1-1 1h-4c-0.547 0-1-0.453-1-1v-7h-4c-0.406 0-0.766-0.25-0.922-0.625-0.156-0.359-0.078-0.797 0.219-1.078l7-7c0.187-0.203 0.453-0.297 0.703-0.297s0.516 0.094 0.703 0.297l7 7c0.297 0.281 0.375 0.719 0.219 1.078z">
</path>
</svg></div><input accept="application/pdf,image/bmp,image/gif,image/jpeg,image/png,image/tiff" type="file" autocomplete="off" tabindex="-1" style="display: none;"><input name="patient.addressAttachmentFile"
id="patient-addressAttachmentFile" placeholder="Cliquer ou déposer un fichier" type="text" class="cursor-pointer form-control" aria-invalid="false" value="">
</div>
</div>
</section>
</div>
</div>
</div>
<div class="form-group"><label for="patient-addressContact" class="">Adresse de contact<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve"
width="512px" height="512px" class="tooltip-image" id="addressContactTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label><textarea name="patient.addressContact" id="patient-addressContact" autocomplete="none" class="form-control" aria-invalid="false"></textarea>
<div class="invalid-feedback"></div>
<ul class="list-group"></ul>
</div>
</div>
</div>
<div class="block">
<div class="block-title">Couverture santé de l'assuré</div>
<div class="block-form">
<div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="welfare-primary-socialNumber" class="">Numéro de sécurité sociale<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625"
xml:space="preserve" width="512px" height="512px" class="tooltip-image" id="socialNumberTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label><input name="welfare.primary.socialNumber" id="welfare-primary-socialNumber" placeholder="_ _ _ _ _ _ _ _ _ _ _ _ _" maxlength="13" type="text" class="form-control" aria-invalid="false" value="">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="welfare-primary-proofAttachmentType" class="">Justificatif de droits</label><select name="welfare.primary.proofAttachmentType" id="welfare-primary-proofAttachmentType" class="form-control"
aria-invalid="false">
<option></option>
<option value="9">Attestation d'ouverture de droits à la Sécurité Sociale</option>
<option value="10">Formulaire S2 (ressortissants européens)</option>
</select>
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
<div class="uploadBox col-md-6">
<div class="form-group"><label for="welfare-primary-proofAttachmentFile" class="">Pièce jointe<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625"
xml:space="preserve" width="512px" height="512px" class="tooltip-image" id="proofPrimaryAttachmentFileTooltip">
<g>
<g>
<path
d="M11.812,0C5.289,0,0,5.289,0,11.812s5.289,11.813,11.812,11.813s11.813-5.29,11.813-11.813 S18.335,0,11.812,0z M14.271,18.307c-0.608,0.24-1.092,0.422-1.455,0.548c-0.362,0.126-0.783,0.189-1.262,0.189 c-0.736,0-1.309-0.18-1.717-0.539s-0.611-0.814-0.611-1.367c0-0.215,0.015-0.435,0.045-0.659c0.031-0.224,0.08-0.476,0.147-0.759 l0.761-2.688c0.067-0.258,0.125-0.503,0.171-0.731c0.046-0.23,0.068-0.441,0.068-0.633c0-0.342-0.071-0.582-0.212-0.717 c-0.143-0.135-0.412-0.201-0.813-0.201c-0.196,0-0.398,0.029-0.605,0.09c-0.205,0.063-0.383,0.12-0.529,0.176l0.201-0.828 c0.498-0.203,0.975-0.377,1.43-0.521c0.455-0.146,0.885-0.218,1.29-0.218c0.731,0,1.295,0.178,1.692,0.53 c0.395,0.353,0.594,0.812,0.594,1.376c0,0.117-0.014,0.323-0.041,0.617c-0.027,0.295-0.078,0.564-0.152,0.811l-0.757,2.68 c-0.062,0.215-0.117,0.461-0.167,0.736c-0.049,0.275-0.073,0.485-0.073,0.626c0,0.356,0.079,0.599,0.239,0.728 c0.158,0.129,0.435,0.194,0.827,0.194c0.185,0,0.392-0.033,0.626-0.097c0.232-0.064,0.4-0.121,0.506-0.17L14.271,18.307z M14.137,7.429c-0.353,0.328-0.778,0.492-1.275,0.492c-0.496,0-0.924-0.164-1.28-0.492c-0.354-0.328-0.533-0.727-0.533-1.193 c0-0.465,0.18-0.865,0.533-1.196c0.356-0.332,0.784-0.497,1.28-0.497c0.497,0,0.923,0.165,1.275,0.497 c0.353,0.331,0.53,0.731,0.53,1.196C14.667,6.703,14.49,7.101,14.137,7.429z"
class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></label>
<section>
<div role="button" tabindex="0" class="fileInputBox">
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 26 28" class="icon icon-dl">
<path
d="M20 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM24 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM26 19.5v5c0 0.828-0.672 1.5-1.5 1.5h-23c-0.828 0-1.5-0.672-1.5-1.5v-5c0-0.828 0.672-1.5 1.5-1.5h6.672c0.422 1.156 1.531 2 2.828 2h4c1.297 0 2.406-0.844 2.828-2h6.672c0.828 0 1.5 0.672 1.5 1.5zM20.922 9.375c-0.156 0.375-0.516 0.625-0.922 0.625h-4v7c0 0.547-0.453 1-1 1h-4c-0.547 0-1-0.453-1-1v-7h-4c-0.406 0-0.766-0.25-0.922-0.625-0.156-0.359-0.078-0.797 0.219-1.078l7-7c0.187-0.203 0.453-0.297 0.703-0.297s0.516 0.094 0.703 0.297l7 7c0.297 0.281 0.375 0.719 0.219 1.078z">
</path>
</svg></div><input accept="application/pdf,image/bmp,image/gif,image/jpeg,image/png,image/tiff" type="file" autocomplete="off" tabindex="-1" style="display: none;"><input name="welfare.primary.proofAttachmentFile"
id="welfare-primary-proofAttachmentFile" placeholder="Cliquer ou déposer un fichier" type="text" class="cursor-pointer form-control" aria-invalid="false" value="">
</div>
</div>
</section>
</div>
</div>
</div>
<div class="row">
<div class="col"><label for="insuredRelationComplement" class="">Si le patient n'est pas l'assuré (le justificatif de droits n'est pas celui du patient), le justificatif est celui du/de la :</label></div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><select name="welfare.primary.insuredRelation" id="insuredRelationComplement" class="form-control" aria-invalid="false">
<option></option>
<option value="Conjointe">Conjointe</option>
<option value="Conjoint">Conjoint</option>
<option value="Mère">Mère</option>
<option value="Père">Père</option>
<option value="Tutrice">Tutrice</option>
<option value="Tuteur">Tuteur</option>
<option value="Soeur">Soeur</option>
<option value="Frère">Frère</option>
<option value="Fille">Fille</option>
<option value="Fils">Fils</option>
<option value="Autre">Autre</option>
</select>
<div class="invalid-feedback"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block">
<div class="block-title">Mutuelle / complémentaire santé</div>
<div class="block-form"><small class="form-text text-muted">Vous n’aurez pas de reste à charge à payer si votre complémentaire santé (mutuelle, C2S, assurance) dispose d’une convention avec l’AP-HP et si elle couvre la totalité des frais. Si ces
deux conditions ne sont pas remplies, vous serez redevable d’une partie des frais : forfait journalier, ticket modérateur, suppléments, etc.</small><br>
<div class="row">
<div class="col">
<fieldset class="radio-group form-group">
<div class="form-check"><input name="welfare.isFonctionnaireAPHP" id="welfare-isFonctionnaireAPHP" type="checkbox" class="form-check-input" aria-invalid="false" value="false"><label for="welfare-isFonctionnaireAPHP"
class="container-radio form-check-label">
<div>Le patient est fonctionnaire de l’AP-HP et souhaite bénéficier du dispositif prévu à du code à
l'<a href="https://www.legifrance.gouv.fr/codes/article_lc/LEGIARTI000044424709/2022-03-01" target="_blank" rel="noopener noreferrer">Article L722-3 </a>de la fonction publique</div>
</label></div>
</fieldset>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="welfare-complement-proofAttachmentType" class="">Justificatif de droits Mutuelle / complémentaire santé</label><select name="welfare.complement.proofAttachmentType"
id="welfare-complement-proofAttachmentType" class="form-control" aria-invalid="false">
<option></option>
<option value="11">Attestation d'assurance</option>
<option value="12">Attestation de mutuelle (soins externes)</option>
</select>
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
<div class="uploadBox col-md-6">
<div class="form-group"><label for="welfare-complement-proofAttachmentFileSide1" class="">Pièce jointe recto<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625"
xml:space="preserve" width="512px" height="512px" class="tooltip-image" id="proofComplementAttachmentFileTooltip">
<g>
<g>
<path
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</g>
</svg></label>
<section>
<div role="button" tabindex="0" class="fileInputBox">
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 26 28" class="icon icon-dl">
<path
d="M20 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM24 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM26 19.5v5c0 0.828-0.672 1.5-1.5 1.5h-23c-0.828 0-1.5-0.672-1.5-1.5v-5c0-0.828 0.672-1.5 1.5-1.5h6.672c0.422 1.156 1.531 2 2.828 2h4c1.297 0 2.406-0.844 2.828-2h6.672c0.828 0 1.5 0.672 1.5 1.5zM20.922 9.375c-0.156 0.375-0.516 0.625-0.922 0.625h-4v7c0 0.547-0.453 1-1 1h-4c-0.547 0-1-0.453-1-1v-7h-4c-0.406 0-0.766-0.25-0.922-0.625-0.156-0.359-0.078-0.797 0.219-1.078l7-7c0.187-0.203 0.453-0.297 0.703-0.297s0.516 0.094 0.703 0.297l7 7c0.297 0.281 0.375 0.719 0.219 1.078z">
</path>
</svg></div><input accept="application/pdf,image/bmp,image/gif,image/jpeg,image/png,image/tiff" type="file" autocomplete="off" tabindex="-1" style="display: none;"><input name="welfare.complement.proofAttachmentFileSide1"
id="welfare-complement-proofAttachmentFileSide1" placeholder="Cliquer ou déposer un fichier" type="text" class="cursor-pointer form-control" aria-invalid="false" value="">
</div>
</div>
</section><label for="welfare-complement-proofAttachmentFileSide2" class="">Pièce jointe verso<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625"
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<g>
<path
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<section>
<div role="button" tabindex="0" class="fileInputBox">
<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 26 28" class="icon icon-dl">
<path
d="M20 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM24 23c0-0.547-0.453-1-1-1s-1 0.453-1 1 0.453 1 1 1 1-0.453 1-1zM26 19.5v5c0 0.828-0.672 1.5-1.5 1.5h-23c-0.828 0-1.5-0.672-1.5-1.5v-5c0-0.828 0.672-1.5 1.5-1.5h6.672c0.422 1.156 1.531 2 2.828 2h4c1.297 0 2.406-0.844 2.828-2h6.672c0.828 0 1.5 0.672 1.5 1.5zM20.922 9.375c-0.156 0.375-0.516 0.625-0.922 0.625h-4v7c0 0.547-0.453 1-1 1h-4c-0.547 0-1-0.453-1-1v-7h-4c-0.406 0-0.766-0.25-0.922-0.625-0.156-0.359-0.078-0.797 0.219-1.078l7-7c0.187-0.203 0.453-0.297 0.703-0.297s0.516 0.094 0.703 0.297l7 7c0.297 0.281 0.375 0.719 0.219 1.078z">
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</svg></div><input accept="application/pdf,image/bmp,image/gif,image/jpeg,image/png,image/tiff" type="file" autocomplete="off" tabindex="-1" style="display: none;"><input name="welfare.complement.proofAttachmentFileSide2"
id="welfare-complement-proofAttachmentFileSide2" placeholder="Cliquer ou déposer un fichier" type="text" class="cursor-pointer form-control" aria-invalid="false" value="">
</div>
</div>
</section>
</div>
</div>
</div>
<div class="my-4 form-check"><input id="hasComplement" name="hasComplement" type="checkbox" class="form-check-input"><label for="hasComplement" class="form-check-label">
<p>Le patient ne bénéficie pas d’une Mutuelle / complémentaire santé</p>
</label></div>
<div class="row">
<div class="col"><label for="insuredRelation" class="">Si le patient n'est pas l'assuré (le justificatif de droits n'est pas celui du patient), le justificatif est celui du/de la :</label></div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><select name="welfare.complement.insuredRelation" id="insuredRelation" class="form-control" aria-invalid="false">
<option></option>
<option value="Conjointe">Conjointe</option>
<option value="Conjoint">Conjoint</option>
<option value="Mère">Mère</option>
<option value="Père">Père</option>
<option value="Tutrice">Tutrice</option>
<option value="Tuteur">Tuteur</option>
<option value="Soeur">Soeur</option>
<option value="Frère">Frère</option>
<option value="Fille">Fille</option>
<option value="Fils">Fils</option>
<option value="Autre">Autre</option>
</select>
<div class="invalid-feedback"></div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-6">
<div class="form-group"><label for="InsurantBirthName" class="">Nom d'usage de l'assuré</label><input name="welfare.complement.InsurantBirthName" id="welfare-complement-InsurantBirthName" type="text" class="form-control"
aria-invalid="false" value="">
<div class="invalid-feedback"></div>
</div>
</div>
<div class="col-md-6">
<div class="form-group"><label for="insurantLastName" class="">Prénom de l'assuré</label><input name="welfare.complement.insurantLastName" id="welfare-complement-insurantLastName" type="text" class="form-control" aria-invalid="false"
value="">
<div class="invalid-feedback"></div>
</div>
</div>
</div>
</div>
</div>
<div class="block">
<div class="block-form">
<div class="row">
<div class="col">
<div class="block-title">Chambre seule</div><small class="form-text text-muted">Le patient dispose d’une complémentaire santé : vous n’aurez rien à payer, sous réserve du contrôle par l’AP-HP de la pièce justificative transmise.</small><br>
<div class="form-check"><input name="welfare.individualRoom" id="welfare-individualRoom" type="checkbox" class="form-check-input" aria-invalid="false" value=""><label for="welfare-individualRoom" class="container-radio form-check-label">Le
patient demande à bénéficier d’une chambre seule</label></div>
</div>
</div>
</div>
</div>
<div class="block">
<div class="captchaBox">
<div class="block-title">Code de sécurité<svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" viewBox="0 0 23.625 23.625" xml:space="preserve" width="512px" height="512px" class="tooltip-image"
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<g>
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class="active-path" fill="#00428b"></path>
</g>
</g>
</svg></div>
<div class="block-form">
<div class="form-group">
<div id="BDC_CaptchaComponent">
<div>
<link type="text/css" rel="stylesheet" href="https://mon.aphp.fr/captcha/simple-captcha-endpoint?get=layout-stylesheet&t=1715090400">
<div class="BDC_CaptchaDiv class1 class2 class3" id="mainCaptchaStyle_CaptchaDiv" style="width: 231px !important; height: 60px !important; "><!--
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<div class="BDC_CaptchaImageDiv" id="mainCaptchaStyle_CaptchaImageDiv" style="width: 200px !important; height: 60px !important;"><!--
-->
<div class="BDC_CaptchaImageDiv" style="width:200px; height:50px;"><img id="mainCaptchaStyle_CaptchaImage" alt="Custom Captcha image tooltip"
src="https://mon.aphp.fr/captcha/simple-captcha-endpoint?get=image&c=mainCaptchaStyle&t=8308df06f6954d42af8ba3eee7574bc2&d=1715085062368"></div>
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<div class="BDC_CaptchaIconsDiv" id="mainCaptchaStyle_CaptchaIconsDiv" style="width: 25px !important;">
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--><a class="BDC_ReloadLink" id="mainCaptchaStyle_ReloadLink" href="#" title="Custom Captcha reload icon tooltip" style="display: inline-block !important;"><img class="BDC_ReloadIcon" id="mainCaptchaStyle_ReloadIcon" src="https://mon.aphp.fr/captcha/simple-captcha-endpoint?get=reload-small-icon" alt="Custom Captcha reload icon tooltip"></a><!--
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<input type="hidden" id="BDC_VCID_mainCaptchaStyle" name="BDC_VCID_mainCaptchaStyle" value="8308df06f6954d42af8ba3eee7574bc2">
<input type="hidden" id="BDC_BackWorkaround_mainCaptchaStyle" name="BDC_BackWorkaround_mainCaptchaStyle" value="0">
<input type="hidden" id="BDC_Hs_mainCaptchaStyle" name="BDC_Hs_mainCaptchaStyle" value="c39d8a3b4c428cf0db47f12724b63e271c3bdea0">
<input type="hidden" id="BDC_SP_mainCaptchaStyle" name="BDC_SP_mainCaptchaStyle" value="1951864615">
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<div class="input-group">
<div class="input-group-prepend"><svg viewBox="0 0 18 28" class="icon icon-lock">
<path d="M5 12h8v-3c0-2.203-1.797-4-4-4s-4 1.797-4 4v3zM18 13.5v9c0 0.828-0.672 1.5-1.5 1.5h-15c-0.828 0-1.5-0.672-1.5-1.5v-9c0-0.828 0.672-1.5 1.5-1.5h0.5v-3c0-3.844 3.156-7 7-7s7 3.156 7 7v3h0.5c0.828 0 1.5 0.672 1.5 1.5z"></path>
</svg></div><input name="captcha.captchaInput" id="captchaUserInput" type="captcha" class="form-control" aria-invalid="false" value="" autocomplete="off" style="text-transform: uppercase;">
<div class="invalid-feedback">Ce champ est requis.</div>
</div>
</div>
</div>
</div>
</div>
<div class="btnBox">
<div class="text-center space row">
<div class="col"><button type="submit" class="btn btn-outline-primary">Envoyer</button></div>
</div>
</div>
</form>Text Content
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browser, please enable JS to make this app work.
Me connecterMenu
* Accueil
* Mes services
* Accès à l’offre de soins
* DEMANDE DE RENDEZ-VOUS
* PRISE DE RENDEZ-VOUS DOCTOLIB
* INSCRIPTION EN MATERNITÉ
* FRÉQUENTATION DES URGENCES
* QUESTIONNAIRE COVID-19
* Démarches administratives
* DOSSIER ADMINISTRATIF
* FACTURES ET PAIEMENTS
* DUPLICATAS
* PRÉFÉRENCES DE RESTAURATION
* Prise en charge médicale
* DOCUMENTS DE SOINS
* PRESCRIPTIONS D'AMP
* QUESTIONNAIRES MÉDICAUX
* SUIVI MÉDICAL HERMES
Me connecter
DOSSIER ADMINISTRATIF
Merci de préparer les pièces justificatives suivantes, elles vous seront
demandées au cours de la procédure :
* - Une pièce d'identité avec photographie
* - Une attestation d'ouverture de droits à la Sécurité sociale
* - Le cas échéant, une copie recto-verso de votre carte mutuelle
Attention, selon les établissements concernés, ce formulaire n'est plus
disponible passé quelques jours avant votre venue à l’hôpital (sauf
téléconsultation et régularisation d'un passage aux urgences ou d'une
hospitalisation). Si tel est le cas, et en l’absence de message vous autorisant
à vous rendre directement en service de soins, vous devrez vous présenter
directement à l’accueil administratif/admissions de l'établissement.
En savoir plus
À défaut, vous êtes susceptible de recevoir une facture pour tout ou partie des
frais liés aux soins. Pour en savoir plus, merci de vous reporter à la FAQ.
À ce titre, il vous est demandé des informations relatives à votre identité et à
la protection sociale dont vous bénéficiez. Ces informations nominatives sont
transmises pour vous faciliter l’accès aux soins et vous permettre de bénéficier
d'une dispense d’avance des frais de santé. Pour en savoir plus, merci de vous
reporter aux mentions légales.
Si vous n’êtes pas assuré social en France, merci de contacter la cellule
internationale de l’hôpital concerné. Des informations sur votre accueil sont
disponibles sur la page dédiée du site Internet de l’AP-HP.
Si vous rencontrez le moindre problème technique au cours du remplissage du
formulaire, n'hésitez pas à contacter le support.
Vous êtes déjà patient de l’AP-HP ? Utilisez FranceConnect pour générer votre
attestation de droits d’Assurance maladie automatiquement.
DOSSIER ADMINISTRATIF
IEP (facultatif)
Je prépare :
mon dossier
le dossier d'un patient mineur ou majeur protégé
Pour :
préparer une téléconsultation
préparer une consultation
préparer une hospitalisation
régulariser un passage aux urgences ou une hospitalisation
LIEU ET DATE DE PRISE EN CHARGE
Établissement
Ce champ est requis.
UH (si connu)
Service
Médecin
Date
Ce champ est requis.
IDENTITÉ ET COORDONNÉES DU PATIENT
IPP (si connu)
Nom de naissance
Ce champ est requis.
Nom d'usage
Prénom
Ce champ est requis.
Sexe
Femme
Homme
Date de naissance
Ce champ est requis.
Pays de naissanceAfghanistanAfrique du
SudAlbanieAlgérieAllemagneAndorreAngolaAnguillaAntarctiqueAntigua-et-BarbudaAntilles
NéerlandaisesArabie
SaouditeArgentineArménieArubaAustralieAutricheAzerbaïdjanBahamasBahreïnBangladeshBarbadeBélarusBelgiqueBelizeBéninBermudesBhoutanBolivieBosnie-HerzégovineBotswanaBrésilBrunéi
DarussalamBulgarieBurkina
FasoBurundiCambodgeCamerounCanadaCap-vertChiliChineChypreColombieComoresCosta
RicaCôte d'IvoireCroatieCubaDanemarkDjiboutiDominiqueÉgypteEl SalvadorÉmirats
Arabes UnisÉquateurÉrythréeEspagneEstonieÉtats Fédérés de
MicronésieÉtats-UnisÉthiopieFédération de
RussieFidjiFinlandeFranceGabonGambieGéorgieGéorgie du Sud et les Îles Sandwich
du
SudGhanaGibraltarGrèceGrenadeGroenlandGuadeloupeGuamGuatemalaGuinéeGuinée-BissauGuinée
ÉquatorialeGuyanaGuyane FrançaiseHaïtiHondurasHong-KongHongrieÎle BouvetÎle
ChristmasÎle de ManÎle NorfolkÎles ÅlandÎles CaïmanesÎles Cocos (Keeling)Îles
CookÎles FéroéÎles Heard et McdonaldÎles (malvinas) FalklandÎles Mariannes du
NordÎles MarshallÎles Mineures Éloignées des États-UnisÎles SalomonÎles Turks et
CaïquesÎles Vierges BritanniquesÎles Vierges des
États-UnisIndeIndonésieIraqIrlandeIslandeIsraëlItalieJamahiriya Arabe
LibyenneJamaïqueJaponJordanieKazakhstanKenyaKirghizistanKiribatiKoweïtLesothoLettonieL'ex-République
Yougoslave de
MacédoineLibanLibériaLiechtensteinLituanieLuxembourgMacaoMadagascarMalaisieMalawiMaldivesMaliMalteMarocMartiniqueMauriceMauritanieMayotteMexiqueMonacoMongolieMontserratMozambiqueMyanmarNamibieNauruNépalNicaraguaNigerNigériaNiuéNorvègeNouvelle-CalédonieNouvelle-ZélandeOmanOugandaOuzbékistanPakistanPalaosPanamaPapouasie-Nouvelle-GuinéeParaguayPays-BasPérouPhilippinesPitcairnPolognePolynésie
FrançaisePorto RicoPortugalQatarRépublique Arabe SyrienneRépublique
CentrafricaineRépublique de CoréeRépublique Démocratique du CongoRépublique
Démocratique Populaire LaoRépublique de MoldovaRépublique DominicaineRépublique
du CongoRépublique Islamique d'IranRépublique Populaire Démocratique de
CoréeRépublique TchèqueRépublique-Unie de
TanzanieRéunionRoumanieRoyaume-UniRwandaSahara
OccidentalSainte-HélèneSainte-LucieSaint-Kitts-et-NevisSaint-MarinSaint-Pierre-et-MiquelonSaint-Siège
(état de la Cité du Vatican)Saint-Vincent-et-les GrenadinesSamoaSamoa
AméricainesSao Tomé-et-PrincipeSénégalSerbie-et-MonténégroSeychellesSierra
LeoneSingapourSlovaquieSlovénieSomalieSoudanSri LankaSuèdeSuisseSurinameSvalbard
etÎle Jan MayenSwazilandTadjikistanTaïwanTchadTerres Australes
FrançaisesTerritoire Britannique de l'Océan IndienTerritoire Palestinien
OccupéThaïlandeTimor-LesteTogoTokelauTongaTrinité-et-TobagoTunisieTurkménistanTurquieTuvaluUkraineUruguayVanuatuVenezuelaViet
NamWallis et FutunaYémenZambieZimbabwe
Ville de naissance
Ce champ est requis.
ADRESSES ET JUSTIFICATIFS DU PATIENT
Pièce d'identitéCarte d'identitéPasseportTitre de séjour
Ce champ est requis.
Pièce jointe (uniquement recto demandé)
Numéro de téléphone
Ce champ est requis.
Adresse e-mail
Ce champ est requis.
Adresse principale
Ce champ est requis.
Justificatif de domicileFacture d'électricité ou de gazTaxe d'habitation ou
foncière
Pièce jointe
Adresse de contact
Couverture santé de l'assuré
Numéro de sécurité sociale
Ce champ est requis.
Justificatif de droitsAttestation d'ouverture de droits à la Sécurité
SocialeFormulaire S2 (ressortissants européens)
Ce champ est requis.
Pièce jointe
Si le patient n'est pas l'assuré (le justificatif de droits n'est pas celui du
patient), le justificatif est celui du/de la :
ConjointeConjointMèrePèreTutriceTuteurSoeurFrèreFilleFilsAutre
Mutuelle / complémentaire santé
Vous n’aurez pas de reste à charge à payer si votre complémentaire santé
(mutuelle, C2S, assurance) dispose d’une convention avec l’AP-HP et si elle
couvre la totalité des frais. Si ces deux conditions ne sont pas remplies, vous
serez redevable d’une partie des frais : forfait journalier, ticket modérateur,
suppléments, etc.
Le patient est fonctionnaire de l’AP-HP et souhaite bénéficier du dispositif
prévu à du code à l'Article L722-3 de la fonction publique
Justificatif de droits Mutuelle / complémentaire santéAttestation
d'assuranceAttestation de mutuelle (soins externes)
Ce champ est requis.
Pièce jointe recto
Pièce jointe verso
Le patient ne bénéficie pas d’une Mutuelle / complémentaire santé
Si le patient n'est pas l'assuré (le justificatif de droits n'est pas celui du
patient), le justificatif est celui du/de la :
ConjointeConjointMèrePèreTutriceTuteurSoeurFrèreFilleFilsAutre
Nom d'usage de l'assuré
Prénom de l'assuré
Chambre seule
Le patient dispose d’une complémentaire santé : vous n’aurez rien à payer, sous
réserve du contrôle par l’AP-HP de la pièce justificative transmise.
Le patient demande à bénéficier d’une chambre seule
Code de sécurité
Custom Captcha help link text
Ce champ est requis.
Envoyer
L’AP-HP collecte vos données en tant que responsable de traitement pour vous
permettre de bénéficier des services en ligne offerts sur l’espace patient «
mon.aphp.fr ».
Pour en savoir plus sur le traitement de vos données personnelles et pour
exercer vos droits, notamment vous opposer à leur réutilisation à des fins de
recherche en santé, vous pouvez consulter la politique de confidentialité
intégrée dans les CGU et disponible ici.
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