{"id":8503,"date":"2025-10-12T17:42:01","date_gmt":"2025-10-12T15:42:01","guid":{"rendered":"https:\/\/clinicabenissa.com\/?page_id=8503"},"modified":"2025-10-12T18:35:29","modified_gmt":"2025-10-12T16:35:29","slug":"changement-dinscription","status":"publish","type":"page","link":"https:\/\/clinicabenissa.com\/fr\/changement-dinscription\/","title":{"rendered":"Enregistrer ou modifier des donn\u00e9es"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"8503\" class=\"elementor elementor-8503\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1de0ccf e-flex e-con-boxed e-con e-parent\" data-id=\"1de0ccf\" data-element_type=\"container\" data-e-type=\"container\" id=\"titulo-principal\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b3bea0f elementor-widget elementor-widget-heading\" data-id=\"b3bea0f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Enregistrer ou modifier des donn\u00e9es<\/h1>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d111185 espsup espinf e-flex e-con-boxed e-con e-parent\" data-id=\"d111185\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ce6183d elementor-widget elementor-widget-text-editor\" data-id=\"ce6183d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Utilisez le formulaire ci-dessous pour vous inscrire en tant que patient ou pour modifier vos coordonn\u00e9es.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fea8839 elementor-widget elementor-widget-shortcode\" data-id=\"fea8839\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/fr\/wp-json\/wp\/v2\/pages\/8503#gf_2' data-formid='2' novalidate data-trp-original-action=\"\/fr\/wp-json\/wp\/v2\/pages\/8503#gf_2\">\n        <div id='gf_progressbar_wrapper_2' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">\u00c9tape <span class='gf_step_current_page'>1<\/span> sud <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_29\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_29'>Instagram<\/label><div class='ginput_container'><input name='input_29' id='input_2_29' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_29'>Ce champion n'est utilis\u00e9 qu'\u00e0 des fins de validation et doit rester gonfl\u00e9.<\/div><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informations personnelles<\/h3><\/div><div id=\"field_2_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_1'>Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='large'    placeholder='Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom * Nom' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>Nom de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='large'    placeholder='Nom de famille* Nom de famille* Nom de famille* Nom de famille* Nom de famille* Nom de famille* Nom de famille* Nom de famille' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_2_3' type='email' value='' class='large'   placeholder='Email * Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='large'    placeholder='T\u00e9l\u00e9phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Date de naissance* Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_2_9' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date de naissance' aria-describedby=\"input_2_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_9_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_9' class='gform_hidden' value='https:\/\/clinicabenissa.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Nationalit\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='' class='large'    placeholder='Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9 * Nationalit\u00e9' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'>Assurance maladie<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='large'    placeholder='Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie * Assurance maladie' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Num\u00e9ro de police<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='large'    placeholder='Num\u00e9ro de police* Num\u00e9ro de police* Num\u00e9ro de police' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_25' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Adresse en Espagne<\/h3><\/div><div id=\"field_2_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Rue<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'    placeholder='Rue' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>Num\u00e9ro d'adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_2_17' type='text' value='' class='large'    placeholder='Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre * Nombre *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Code postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='large'    placeholder='Code postal* Code postal* Code postal* Code postal* Code postal' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-text 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value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_2_26' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Ant\u00e9c\u00e9dents m\u00e9dicaux<\/h3><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-27' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Message<\/h3><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label 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gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_5.1' id='input_2_5_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_5\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_5_1' >J'ai lu et j'accepte les <a href=\"\/fr\/politique-de-confidentialite\/\" target=\"_blank\">POLITIQUE DE CONFIDENTIALIT\u00c9<\/a><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/label><input type='hidden' name='input_5.2' value='He le\u00eddo y acepto la &lt;a href=&quot;\/politica-de-privacidad\/&quot; target=&quot;_blank&quot;&gt;pol\u00edtica de privacidad&lt;\/a&gt;' class='gform_hidden' \/><input type='hidden' name='input_5.3' value='3' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_5' tabindex='0'>MARIA ALEXANDRA RODRIGUEZ CORTES en tant que propri\u00e9taire de clinicabenissa.com , je vous demande votre consentement pour r\u00e9pondre aux questions pos\u00e9es \u00e0 travers le formulaire. 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