{"id":166,"date":"2016-08-30T17:39:32","date_gmt":"2016-08-30T15:39:32","guid":{"rendered":"https:\/\/www.vivreplushollister.com\/stomie\/?page_id=166"},"modified":"2025-03-13T13:31:40","modified_gmt":"2025-03-13T12:31:40","slug":"inscription-au-club","status":"publish","type":"page","link":"https:\/\/www.vivreplushollister.com\/stomie\/inscription-au-club\/","title":{"rendered":"Inscription au Club"},"content":{"rendered":"\n<h1>\n\t\tQUEL NIVEAU DE SERVICES SOUHAITEZ VOUS\u00a0?\n\t<\/h1>\n\t<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_6_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_frmprocontact2\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_hidden\">Inscription au Club<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"6\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_6\" id=\"frm_hide_fields_6\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"frmprocontact2\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_6\" name=\"frm_submit_entry_6\" value=\"b8a15d453f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/stomie\/wp-json\/wp\/v2\/pages\/166\" \/><div id=\"frm_field_74_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_third\">\r\n    <label for=\"field_rwkyi\" class=\"frm_primary_label\">Civilit\u00e9\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[74]\" id=\"field_rwkyi\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Civilit\u00e9 est non valide\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Madame\">Madame<\/option><option  value=\"Monsieur\">Monsieur<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_wwtp302\" class=\"frm_primary_label\">Nom\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_wwtp302\" name=\"item_meta[64]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Nom est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_oag1ms2\" class=\"frm_primary_label\">Pr\u00e9nom\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_oag1ms2\" name=\"item_meta[65]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Pr\u00e9nom est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_3l3cwp2\" class=\"frm_primary_label\">Adresse\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_3l3cwp2\" name=\"item_meta[68]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Adresse est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_xk12lc2\" class=\"frm_primary_label\">Code postal\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_xk12lc2\" name=\"item_meta[72]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Code postal est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_w8z3lb2\" class=\"frm_primary_label\">Ville\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_w8z3lb2\" name=\"item_meta[70]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Ville est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_73_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_j9nrol2\" class=\"frm_primary_label\">Pays\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[73]\" id=\"field_j9nrol2\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Pays est non valide\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Afghanistan\">Afghanistan<\/option><option  value=\"Albania\">Albania<\/option><option  value=\"Algeria\">Algeria<\/option><option  value=\"American Samoa\">American Samoa<\/option><option  value=\"Andorra\">Andorra<\/option><option  value=\"Angola\">Angola<\/option><option  value=\"Anguilla\">Anguilla<\/option><option  value=\"Antarctica\">Antarctica<\/option><option  value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option  value=\"Argentina\">Argentina<\/option><option  value=\"Armenia\">Armenia<\/option><option  value=\"Aruba\">Aruba<\/option><option  value=\"Australia\">Australia<\/option><option  value=\"Austria\">Austria<\/option><option  value=\"Azerbaijan\">Azerbaijan<\/option><option  value=\"Bahamas\">Bahamas<\/option><option  value=\"Bahrain\">Bahrain<\/option><option  value=\"Bangladesh\">Bangladesh<\/option><option  value=\"Barbados\">Barbados<\/option><option  value=\"Belarus\">Belarus<\/option><option  value=\"Belgium\">Belgium<\/option><option  value=\"Belize\">Belize<\/option><option  value=\"Benin\">Benin<\/option><option  value=\"Bermuda\">Bermuda<\/option><option  value=\"Bhutan\">Bhutan<\/option><option  value=\"Bolivia\">Bolivia<\/option><option  value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option  value=\"Botswana\">Botswana<\/option><option  value=\"Bouvet Island\">Bouvet Island<\/option><option  value=\"Brazil\">Brazil<\/option><option  value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option  value=\"Brunei\">Brunei<\/option><option  value=\"Bulgaria\">Bulgaria<\/option><option  value=\"Burkina Faso\">Burkina Faso<\/option><option  value=\"Burundi\">Burundi<\/option><option  value=\"Cambodia\">Cambodia<\/option><option  value=\"Cameroon\">Cameroon<\/option><option  value=\"Canada\">Canada<\/option><option  value=\"Cape Verde\">Cape Verde<\/option><option  value=\"Cayman Islands\">Cayman Islands<\/option><option  value=\"Central African Republic\">Central African Republic<\/option><option  value=\"Chad\">Chad<\/option><option  value=\"Chile\">Chile<\/option><option  value=\"China\">China<\/option><option  value=\"Christmas Island\">Christmas Island<\/option><option  value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option><option  value=\"Colombia\">Colombia<\/option><option  value=\"Comoros\">Comoros<\/option><option  value=\"Congo\">Congo<\/option><option  value=\"Cook Islands\">Cook Islands<\/option><option  value=\"Costa Rica\">Costa Rica<\/option><option  value=\"C\u00f4te d&#039;Ivoire\">C\u00f4te d&#039;Ivoire<\/option><option  value=\"Croatia (Hrvatska)\">Croatia (Hrvatska)<\/option><option  value=\"Cuba\">Cuba<\/option><option  value=\"Cyprus\">Cyprus<\/option><option  value=\"Czech Republic\">Czech Republic<\/option><option  value=\"Congo (DRC)\">Congo (DRC)<\/option><option  value=\"Denmark\">Denmark<\/option><option  value=\"Djibouti\">Djibouti<\/option><option  value=\"Dominica\">Dominica<\/option><option  value=\"Dominican Republic\">Dominican Republic<\/option><option  value=\"East Timor\">East Timor<\/option><option  value=\"Ecuador\">Ecuador<\/option><option  value=\"Egypt\">Egypt<\/option><option  value=\"El Salvador\">El Salvador<\/option><option  value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option  value=\"Eritrea\">Eritrea<\/option><option  value=\"Estonia\">Estonia<\/option><option  value=\"Ethiopia\">Ethiopia<\/option><option  value=\"Falkland Islands (Islas Malvinas)\">Falkland Islands (Islas Malvinas)<\/option><option  value=\"Faroe Islands\">Faroe Islands<\/option><option  value=\"Fiji Islands\">Fiji Islands<\/option><option  value=\"Finland\">Finland<\/option><option  value=\"France\">France<\/option><option  value=\"French Guiana\">French Guiana<\/option><option  value=\"French Polynesia\">French Polynesia<\/option><option  value=\"French Southern and Antarctic Lands\">French Southern and Antarctic Lands<\/option><option  value=\"Gabon\">Gabon<\/option><option  value=\"Gambia\">Gambia<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Germany\">Germany<\/option><option  value=\"Ghana\">Ghana<\/option><option  value=\"Gibraltar\">Gibraltar<\/option><option  value=\"Greece\">Greece<\/option><option  value=\"Greenland\">Greenland<\/option><option  value=\"Grenada\">Grenada<\/option><option  value=\"Guadeloupe\">Guadeloupe<\/option><option  value=\"Guam\">Guam<\/option><option  value=\"Guatemala\">Guatemala<\/option><option  value=\"Guinea\">Guinea<\/option><option  value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option  value=\"Guyana\">Guyana<\/option><option  value=\"Haiti\">Haiti<\/option><option  value=\"Honduras\">Honduras<\/option><option  value=\"Hong Kong SAR\">Hong Kong SAR<\/option><option  value=\"Hungary\">Hungary<\/option><option  value=\"Iceland\">Iceland<\/option><option  value=\"India\">India<\/option><option  value=\"Indonesia\">Indonesia<\/option><option  value=\"Iran\">Iran<\/option><option  value=\"Iraq\">Iraq<\/option><option  value=\"Ireland\">Ireland<\/option><option  value=\"Israel\">Israel<\/option><option  value=\"Italy\">Italy<\/option><option  value=\"Jamaica\">Jamaica<\/option><option  value=\"Japan\">Japan<\/option><option  value=\"Jordan\">Jordan<\/option><option  value=\"Kazakhstan\">Kazakhstan<\/option><option  value=\"Kenya\">Kenya<\/option><option  value=\"Kiribati\">Kiribati<\/option><option  value=\"Korea\">Korea<\/option><option  value=\"Kuwait\">Kuwait<\/option><option  value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option  value=\"Laos\">Laos<\/option><option  value=\"Latvia\">Latvia<\/option><option  value=\"Lebanon\">Lebanon<\/option><option  value=\"Lesotho\">Lesotho<\/option><option  value=\"Liberia\">Liberia<\/option><option  value=\"Libya\">Libya<\/option><option  value=\"Liechtenstein\">Liechtenstein<\/option><option  value=\"Lithuania\">Lithuania<\/option><option  value=\"Luxembourg\">Luxembourg<\/option><option  value=\"Macao SAR\">Macao SAR<\/option><option  value=\"Macedonia, Former Yugoslav Republic of\">Macedonia, Former Yugoslav Republic of<\/option><option  value=\"Madagascar\">Madagascar<\/option><option  value=\"Malawi\">Malawi<\/option><option  value=\"Malaysia\">Malaysia<\/option><option  value=\"Maldives\">Maldives<\/option><option  value=\"Mali\">Mali<\/option><option  value=\"Malta\">Malta<\/option><option  value=\"Marshall Islands\">Marshall Islands<\/option><option  value=\"Martinique\">Martinique<\/option><option  value=\"Mauritania\">Mauritania<\/option><option  value=\"Mauritius\">Mauritius<\/option><option  value=\"Mayotte\">Mayotte<\/option><option  value=\"Mexico\">Mexico<\/option><option  value=\"Micronesia\">Micronesia<\/option><option  value=\"Moldova\">Moldova<\/option><option  value=\"Monaco\">Monaco<\/option><option  value=\"Mongolia\">Mongolia<\/option><option  value=\"Montserrat\">Montserrat<\/option><option  value=\"Morocco\">Morocco<\/option><option  value=\"Mozambique\">Mozambique<\/option><option  value=\"Myanmar\">Myanmar<\/option><option  value=\"Namibia\">Namibia<\/option><option  value=\"Nauru\">Nauru<\/option><option  value=\"Nepal\">Nepal<\/option><option  value=\"Netherlands\">Netherlands<\/option><option  value=\"New Zealand\">New Zealand<\/option><option  value=\"Nicaragua\">Nicaragua<\/option><option  value=\"Niger\">Niger<\/option><option  value=\"Nigeria\">Nigeria<\/option><option  value=\"Norway\">Norway<\/option><option  value=\"Oman\">Oman<\/option><option  value=\"Pakistan\">Pakistan<\/option><option  value=\"Palau\">Palau<\/option><option  value=\"Palestine\">Palestine<\/option><option  value=\"Panama\">Panama<\/option><option  value=\"Papua New Guinea\">Papua New Guinea<\/option><option  value=\"Paraguay\">Paraguay<\/option><option  value=\"Peru\">Peru<\/option><option  value=\"Philippines\">Philippines<\/option><option  value=\"Poland\">Poland<\/option><option  value=\"Portugal\">Portugal<\/option><option  value=\"Puerto Rico\">Puerto Rico<\/option><option  value=\"Qatar\">Qatar<\/option><option  value=\"Romania\">Romania<\/option><option  value=\"Russia\">Russia<\/option><option  value=\"Rwanda\">Rwanda<\/option><option  value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option  value=\"Saint Lucia\">Saint Lucia<\/option><option  value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option  value=\"Samoa\">Samoa<\/option><option  value=\"San Marino\">San Marino<\/option><option  value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option  value=\"Saudi Arabia\">Saudi Arabia<\/option><option  value=\"Senegal\">Senegal<\/option><option  value=\"Serbia and Montenegro\">Serbia and Montenegro<\/option><option  value=\"Seychelles\">Seychelles<\/option><option  value=\"Sierra Leone\">Sierra Leone<\/option><option  value=\"Singapore\">Singapore<\/option><option  value=\"Slovakia\">Slovakia<\/option><option  value=\"Slovenia\">Slovenia<\/option><option  value=\"Solomon Islands\">Solomon Islands<\/option><option  value=\"Somalia\">Somalia<\/option><option  value=\"South Africa\">South Africa<\/option><option  value=\"Spain\">Spain<\/option><option  value=\"Sri Lanka\">Sri Lanka<\/option><option  value=\"Sudan\">Sudan<\/option><option  value=\"Suriname\">Suriname<\/option><option  value=\"Swaziland\">Swaziland<\/option><option  value=\"Sweden\">Sweden<\/option><option  value=\"Switzerland\">Switzerland<\/option><option  value=\"Syria\">Syria<\/option><option  value=\"Taiwan\">Taiwan<\/option><option  value=\"Tajikistan\">Tajikistan<\/option><option  value=\"Tanzania\">Tanzania<\/option><option  value=\"Thailand\">Thailand<\/option><option  value=\"Togo\">Togo<\/option><option  value=\"Tonga\">Tonga<\/option><option  value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option  value=\"Tunisia\">Tunisia<\/option><option  value=\"Turkey\">Turkey<\/option><option  value=\"Turkmenistan\">Turkmenistan<\/option><option  value=\"Tuvalu\">Tuvalu<\/option><option  value=\"Uganda\">Uganda<\/option><option  value=\"Ukraine\">Ukraine<\/option><option  value=\"United Arab Emirates\">United Arab Emirates<\/option><option  value=\"United Kingdom\">United Kingdom<\/option><option  value=\"United States\">United States<\/option><option  value=\"Uruguay\">Uruguay<\/option><option  value=\"Uzbekistan\">Uzbekistan<\/option><option  value=\"Vanuatu\">Vanuatu<\/option><option  value=\"Vatican City\">Vatican City<\/option><option  value=\"Venezuela\">Venezuela<\/option><option  value=\"Vietnam\">Vietnam<\/option><option  value=\"Yemen\">Yemen<\/option><option  value=\"Zambia\">Zambia<\/option><option  value=\"Zimbabwe\">Zimbabwe<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_rlh36\" class=\"frm_primary_label\">Date de naissance\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_rlh36\" name=\"item_meta[75]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Date de naissance est non valide\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_z937s\" class=\"frm_primary_label\">Num\u00e9ro de t\u00e9l\u00e9phone\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_z937s\" name=\"item_meta[76]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Num\u00e9ro de t\u00e9l\u00e9phone est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xnkv8k2\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_xnkv8k2\" name=\"item_meta[66]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Please enter a valid email address\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_xnkv8k2\"\/>\r\n    <div id=\"frm_desc_field_xnkv8k2\" class=\"frm_description\">Sera votre identifiant pour vous connecter \u00e0 l\u2019espace membre<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_161_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_ccc0u\" class=\"frm_primary_label\">Mot de passe\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"password\" id=\"field_ccc0u\" name=\"item_meta[161]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Mot de passe est non valide\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_ccc0u\"\/>\r\n    <div id=\"frm_desc_field_ccc0u\" class=\"frm_description\">Entrez le mot de passe<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_conf_161_container\" class=\"frm_form_field frm_hidden_container frm_conf_field form-field  frm_required_field frm_top_container  frm6\">\r\n    <label for=\"field_conf_ccc0u\" class=\"frm_conf_label frm_primary_label\">Valider Mot de passe\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"password\" id=\"field_conf_ccc0u\" name=\"item_meta[conf_161]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-confmsg=\"Les valeurs saisies ne correspondent pas\" data-invmsg=\"Mot de passe est non valide\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_conf_ccc0u\"\/>\r\n    <div id=\"frm_desc_field_conf_ccc0u\" class=\"frm_description\">Confirmez le mot de passe<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half vertical_radio\">\r\n    <label  class=\"frm_primary_label\">Utilisez-vous du mat\u00e9riel de stomath\u00e9rapie ?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_77-0\">\t\t\t<label  for=\"field_lkauy-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[77]\" id=\"field_lkauy-0\" value=\"Oui\"\n\t\t data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" data-invmsg=\"Utilisez-vous du mat\u00e9riel de stomath\u00e9rapie ? est non valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_77-1\">\t\t\t<label  for=\"field_lkauy-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[77]\" id=\"field_lkauy-1\" value=\"Non\"\n\t\t data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" data-invmsg=\"Utilisez-vous du mat\u00e9riel de stomath\u00e9rapie ? est non valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_160_container\" class=\"frm_form_field form-field  frm_top_container frm_half vertical_radio\">\r\n    <label  class=\"frm_primary_label\">\u00cates-vous un proche d'un utilisateur de mat\u00e9riel de stomath\u00e9rapie ?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_160-0\">\t\t\t<label  for=\"field_l6wvk-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[160]\" id=\"field_l6wvk-0\" value=\"Oui\"\n\t\t data-invmsg=\"\u00cates-vous un proche d&#039;un utilisateur de mat\u00e9riel de stomath\u00e9rapie ? est non valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_160-1\">\t\t\t<label  for=\"field_l6wvk-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[160]\" id=\"field_l6wvk-1\" value=\"Non\"\n\t\t data-invmsg=\"\u00cates-vous un proche d&#039;un utilisateur de mat\u00e9riel de stomath\u00e9rapie ? est non valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half horizontal_radio\">\r\n    <label  class=\"frm_primary_label\">Type de stomie\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_79-0\">\t\t\t<label  for=\"field_imfvx-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[79]\" id=\"field_imfvx-0\" value=\"Colostomie\"\n\t\t data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" data-invmsg=\"Type de stomie est non valide\"   \/> Colostomie<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_79-1\">\t\t\t<label  for=\"field_imfvx-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[79]\" id=\"field_imfvx-1\" value=\"Il\u00e9ostomie\"\n\t\t data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" data-invmsg=\"Type de stomie est non valide\"   \/> Il\u00e9ostomie<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_79-2\">\t\t\t<label  for=\"field_imfvx-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[79]\" id=\"field_imfvx-2\" value=\"Urostomie\"\n\t\t data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" data-invmsg=\"Type de stomie est non valide\"   \/> Urostomie<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_159_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_wqsnm\" class=\"frm_primary_label\">Date de l'intervention (r\u00e9alis\u00e9e ou programm\u00e9e)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_wqsnm\" name=\"item_meta[159]\" value=\"\"  maxlength=\"10\" data-invmsg=\"Date de naissance est non valide\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_188_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_two_thirds\">\n\t<label for=\"field_4b6o9\" id=\"field_4b6o9_label\" class=\"frm_primary_label\">Etablissement o\u00f9 a \u00e9t\u00e9 mise en place la stomie\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t<input  type=\"text\" id=\"field_4b6o9\" name=\"item_meta[188]\" value=\"\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Etablissement o\u00f9 a \u00e9t\u00e9 mise en place la stomie est non valide\" aria-invalid=\"false\"   \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_189_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\n\t<label for=\"field_zbi1u\" id=\"field_zbi1u_label\" class=\"frm_primary_label\">D\u00e9partement de l\u2019\u00e9tablissement\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\n\t<\/label>\n\t\t\t<select name=\"item_meta[189]\" id=\"field_zbi1u\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"D\u00e9partement de l\u2019\u00e9tablissement est non valide\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"01 - Ain\">01 - Ain<\/option><option  value=\"02 - Aisne\">02 - Aisne<\/option><option  value=\"03 - Allier\">03 - Allier<\/option><option  value=\"04 - Alpes-de-Haute-Provence\">04 - Alpes-de-Haute-Provence<\/option><option  value=\"05 - Hautes-alpes\">05 - Hautes-alpes<\/option><option  value=\"06 - Alpes-maritimes\">06 - Alpes-maritimes<\/option><option  value=\"07 - Ard\u00e8che\">07 - Ard\u00e8che<\/option><option  value=\"08 - Ardennes\">08 - Ardennes<\/option><option  value=\"09 - Ari\u00e8ge\">09 - Ari\u00e8ge<\/option><option  value=\"10 - Aube\">10 - Aube<\/option><option  value=\"11 - Aude\">11 - Aude<\/option><option  value=\"12 - Aveyron\">12 - Aveyron<\/option><option  value=\"13 - Bouches-du-Rh\u00f4ne\">13 - Bouches-du-Rh\u00f4ne<\/option><option  value=\"14 - Calvados\">14 - Calvados<\/option><option  value=\"15 - Cantal\">15 - Cantal<\/option><option  value=\"16 - Charente\">16 - Charente<\/option><option  value=\"17 - Charente-maritime\">17 - Charente-maritime<\/option><option  value=\"18 - Cher\">18 - Cher<\/option><option  value=\"19 - Corr\u00e8ze\">19 - Corr\u00e8ze<\/option><option  value=\"2A - Corse-du-sud\">2A - Corse-du-sud<\/option><option  value=\"2B - Haute-Corse\">2B - Haute-Corse<\/option><option  value=\"21 - C\u00f4te-d&#039;Or\">21 - C\u00f4te-d&#039;Or<\/option><option  value=\"22 - C\u00f4tes-d&#039;Armor\">22 - C\u00f4tes-d&#039;Armor<\/option><option  value=\"23 - Creuse\">23 - Creuse<\/option><option  value=\"24 - Dordogne\">24 - Dordogne<\/option><option  value=\"25 - Doubs\">25 - Doubs<\/option><option  value=\"26 - Dr\u00f4me\">26 - Dr\u00f4me<\/option><option  value=\"27 - Eure\">27 - Eure<\/option><option  value=\"28 - Eure-et-loir\">28 - Eure-et-loir<\/option><option  value=\"29 - Finist\u00e8re\">29 - Finist\u00e8re<\/option><option  value=\"30 - Gard\">30 - Gard<\/option><option  value=\"31 - Haute-garonne\">31 - Haute-garonne<\/option><option  value=\"32 - Gers\">32 - Gers<\/option><option  value=\"33 - Gironde\">33 - Gironde<\/option><option  value=\"34 - H\u00e9rault\">34 - H\u00e9rault<\/option><option  value=\"35 - Ille-et-vilaine\">35 - Ille-et-vilaine<\/option><option  value=\"36 - Indre\">36 - Indre<\/option><option  value=\"37 - Indre-et-loire\">37 - Indre-et-loire<\/option><option  value=\"38 - Is\u00e8re\">38 - Is\u00e8re<\/option><option  value=\"39 - Jura\">39 - Jura<\/option><option  value=\"40 - Landes\">40 - Landes<\/option><option  value=\"41 - Loir-et-cher\">41 - Loir-et-cher<\/option><option  value=\"42 - Loire\">42 - Loire<\/option><option  value=\"43 - Haute-loire\">43 - Haute-loire<\/option><option  value=\"44 - Loire-atlantique\">44 - Loire-atlantique<\/option><option  value=\"45 - Loiret\">45 - Loiret<\/option><option  value=\"46 - Lot\">46 - Lot<\/option><option  value=\"47 - Lot-et-garonne\">47 - Lot-et-garonne<\/option><option  value=\"48 - Loz\u00e8re\">48 - Loz\u00e8re<\/option><option  value=\"49 - Maine-et-loire\">49 - Maine-et-loire<\/option><option  value=\"50 - Manche\">50 - Manche<\/option><option  value=\"51 - Marne\">51 - Marne<\/option><option  value=\"52 - Haute-marne\">52 - Haute-marne<\/option><option  value=\"53 - Mayenne\">53 - Mayenne<\/option><option  value=\"54 - Meurthe-et-moselle\">54 - Meurthe-et-moselle<\/option><option  value=\"55 - Meuse\">55 - Meuse<\/option><option  value=\"56 - Morbihan\">56 - Morbihan<\/option><option  value=\"57 - Moselle\">57 - Moselle<\/option><option  value=\"58 - Ni\u00e8vre\">58 - Ni\u00e8vre<\/option><option  value=\"59 - Nord\">59 - Nord<\/option><option  value=\"60 - Oise\">60 - Oise<\/option><option  value=\"61 - Orne\">61 - Orne<\/option><option  value=\"62 - Pas-de-calais\">62 - Pas-de-calais<\/option><option  value=\"63 - Puy-de-d\u00f4me\">63 - Puy-de-d\u00f4me<\/option><option  value=\"64 - Pyr\u00e9n\u00e9es-atlantiques\">64 - Pyr\u00e9n\u00e9es-atlantiques<\/option><option  value=\"65 - Hautes-Pyr\u00e9n\u00e9es\">65 - Hautes-Pyr\u00e9n\u00e9es<\/option><option  value=\"66 - Pyr\u00e9n\u00e9es-orientales\">66 - Pyr\u00e9n\u00e9es-orientales<\/option><option  value=\"67 - Bas-rhin\">67 - Bas-rhin<\/option><option  value=\"68 - Haut-rhin\">68 - Haut-rhin<\/option><option  value=\"69 - Rh\u00f4ne\">69 - Rh\u00f4ne<\/option><option  value=\"70 - Haute-sa\u00f4ne\">70 - Haute-sa\u00f4ne<\/option><option  value=\"71 - Sa\u00f4ne-et-loire\">71 - Sa\u00f4ne-et-loire<\/option><option  value=\"72 - Sarthe\">72 - Sarthe<\/option><option  value=\"73 - Savoie\">73 - Savoie<\/option><option  value=\"74 - Haute-savoie\">74 - Haute-savoie<\/option><option  value=\"75 - Paris\">75 - Paris<\/option><option  value=\"76 - Seine-maritime\">76 - Seine-maritime<\/option><option  value=\"77 - Seine-et-marne\">77 - Seine-et-marne<\/option><option  value=\"78 - Yvelines\">78 - Yvelines<\/option><option  value=\"79 - Deux-s\u00e8vres\">79 - Deux-s\u00e8vres<\/option><option  value=\"80 - Somme\">80 - Somme<\/option><option  value=\"81 - Tarn\">81 - Tarn<\/option><option  value=\"82 - Tarn-et-Garonne\">82 - Tarn-et-Garonne<\/option><option  value=\"83 - Var\">83 - Var<\/option><option  value=\"84 - Vaucluse\">84 - Vaucluse<\/option><option  value=\"85 - Vend\u00e9e\">85 - Vend\u00e9e<\/option><option  value=\"86 - Vienne\">86 - Vienne<\/option><option  value=\"87 - Haute-vienne\">87 - Haute-vienne<\/option><option  value=\"88 - Vosges\">88 - Vosges<\/option><option  value=\"89 - Yonne\">89 - Yonne<\/option><option  value=\"90 - Territoire de belfort\">90 - Territoire de belfort<\/option><option  value=\"91 - Essonne\">91 - Essonne<\/option><option  value=\"92 - Hauts-de-seine\">92 - Hauts-de-seine<\/option><option  value=\"93 - Seine-Saint-Denis\">93 - Seine-Saint-Denis<\/option><option  value=\"94 - Val-de-marne\">94 - Val-de-marne<\/option><option  value=\"95 - Val-d&#039;Oise\">95 - Val-d&#039;Oise<\/option><option  value=\"971 - Guadeloupe\">971 - Guadeloupe<\/option><option  value=\"972 - Martinique\">972 - Martinique<\/option><option  value=\"973 - Guyane\">973 - Guyane<\/option><option  value=\"974 - La r\u00e9union\">974 - La r\u00e9union<\/option><option  value=\"976 - Mayotte\">976 - Mayotte<\/option>\t<\/select>\n\t\n\t\n\t\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first horizontal_radio\">\r\n    <label  class=\"frm_primary_label\">Dur\u00e9e\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_78-0\">\t\t\t<label  for=\"field_crnx4-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[78]\" id=\"field_crnx4-0\" value=\"Permanente\"\n\t\t data-invmsg=\"Dur\u00e9e est non valide\"   \/> Permanente<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_78-1\">\t\t\t<label  for=\"field_crnx4-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[78]\" id=\"field_crnx4-1\" value=\"Temporaire\"\n\t\t data-invmsg=\"Dur\u00e9e est non valide\"   \/> Temporaire<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_top_container frm6 horizontal_radio\">\r\n    <label  class=\"frm_primary_label\">Syst\u00e8me\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_81-0\">\t\t\t<label  for=\"field_uqehl-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[81]\" id=\"field_uqehl-0\" value=\"1 pi\u00e8ce\"\n\t\t data-invmsg=\"Syst\u00e8me est non valide\"   \/> 1 pi\u00e8ce<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_81-1\">\t\t\t<label  for=\"field_uqehl-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[81]\" id=\"field_uqehl-1\" value=\"2 pi\u00e8ces\"\n\t\t data-invmsg=\"Syst\u00e8me est non valide\"   \/> 2 pi\u00e8ces<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_half horizontal_radio\">\r\n    <label  class=\"frm_primary_label\">Type de support\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_83-0\">\t\t\t<label  for=\"field_n5w9p-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_n5w9p-0\" value=\"Plan \/ Plat\"\n\t\t data-invmsg=\"Type de support est non valide\"   \/> Plan \/ Plat<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_83-1\">\t\t\t<label  for=\"field_n5w9p-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_n5w9p-1\" value=\"Convexe\"\n\t\t data-invmsg=\"Type de support est non valide\"   \/> Convexe<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_top_container frm_half vertical_radio\">\r\n    <label  class=\"frm_primary_label\">Type de poche\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_82-0\">\t\t\t<label  for=\"field_9pq0n-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[82]\" id=\"field_9pq0n-0\" value=\"Ferm\u00e9e\"\n\t\t data-invmsg=\"Type de poche est non valide\"   \/> Ferm\u00e9e<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_82-1\">\t\t\t<label  for=\"field_9pq0n-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[82]\" id=\"field_9pq0n-1\" value=\"Haut d\u00e9bit (avec bouchon)\"\n\t\t data-invmsg=\"Type de poche est non valide\"   \/> Haut d\u00e9bit (avec bouchon)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_82-2\">\t\t\t<label  for=\"field_9pq0n-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[82]\" id=\"field_9pq0n-2\" value=\"Vidable\"\n\t\t data-invmsg=\"Type de poche est non valide\"   \/> Vidable<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_82-3\">\t\t\t<label  for=\"field_9pq0n-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[82]\" id=\"field_9pq0n-3\" value=\"Vidangeable (avec robinet)\"\n\t\t data-invmsg=\"Type de poche est non valide\"   \/> Vidangeable (avec robinet)<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_146_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_half vertical_radio\">\r\n    <label  class=\"frm_primary_label\">Accessoires\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_146-0\">\t\t\t<label  for=\"field_ykcwx-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[146][]\" id=\"field_ykcwx-0\" value=\"P\u00e2te\"  data-invmsg=\"Accessoires est non valide\"   \/> P\u00e2te<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_146-1\">\t\t\t<label  for=\"field_ykcwx-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[146][]\" id=\"field_ykcwx-1\" value=\"Spray \/ lingettes retrait adh\u00e9sif\"  data-invmsg=\"Accessoires est non valide\"   \/> Spray \/ lingettes retrait adh\u00e9sif<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_146-2\">\t\t\t<label  for=\"field_ykcwx-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[146][]\" id=\"field_ykcwx-2\" value=\"Poches \u00e0 urines\"  data-invmsg=\"Accessoires est non valide\"   \/> Poches \u00e0 urines<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_146-3\">\t\t\t<label  for=\"field_ykcwx-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[146][]\" id=\"field_ykcwx-3\" value=\"Anneaux\"  data-invmsg=\"Accessoires est non valide\"   \/> Anneaux<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_146-4\">\t\t\t<label  for=\"field_ykcwx-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[146][]\" id=\"field_ykcwx-4\" value=\"D\u00e9sodorisant\"  data-invmsg=\"Accessoires est non valide\"   \/> D\u00e9sodorisant<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_146-5\">\t\t\t<label  for=\"field_ykcwx-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[146][]\" id=\"field_ykcwx-5\" value=\"Lubrifiant\"  data-invmsg=\"Accessoires est non valide\"   \/> Lubrifiant<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_146-6\">\t\t\t<label  for=\"field_ykcwx-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[146][]\" id=\"field_ykcwx-6\" value=\"Filet de maintien ou lani\u00e8res\"  data-invmsg=\"Accessoires est non valide\"   \/> Filet de maintien ou lani\u00e8res<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_half\">\r\n    <label for=\"field_ta1bw\" class=\"frm_primary_label\">Produits \/ marques actuellement utilis\u00e9s :\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_ta1bw\" name=\"item_meta[80]\" value=\"\"  data-invmsg=\"Produits \/ marques actuellement utilis\u00e9s : est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_157_container\" class=\"frm_form_field form-field  frm_top_container frm_half\">\r\n    <label for=\"field_q3a8i\" class=\"frm_primary_label\">R\u00e9f\u00e9rences produits \/ marques du mat\u00e9riel actuellement utilis\u00e9\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_q3a8i\" name=\"item_meta[157]\" value=\"\"  data-invmsg=\"R\u00e9f\u00e9rences produits \/ marques du mat\u00e9riel actuellement utilis\u00e9 est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_164_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio frm_other_container\">\r\n    <label  class=\"frm_primary_label\">Approvisionnement produits\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_164-0\">\t\t\t<label  for=\"field_n6fgo-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[164][]\" id=\"field_n6fgo-0\" value=\"Prestataire de service \u00e0 domicile\"  data-invmsg=\"Approvisionnement produits est non valide\"   \/> Prestataire de service \u00e0 domicile<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_164-1\">\t\t\t<label  for=\"field_n6fgo-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[164][]\" id=\"field_n6fgo-1\" value=\"Pharmacie\"  data-invmsg=\"Approvisionnement produits est non valide\"   \/> Pharmacie<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_164-other_2\">\t\t\t<label  for=\"field_n6fgo-other_2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[164][other_2]\" id=\"field_n6fgo-other_2\" value=\"Autre\"  data-invmsg=\"Approvisionnement produits est non valide\"   \/> Autre<\/label><label for=\"field_n6fgo-other_2-otext\" class=\"frm_screen_reader frm_hidden\">Autre<\/label><input type=\"text\" id=\"field_n6fgo-other_2-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][164][other_2]\" value=\"\" \/><\/div>\n<\/div>\r\n    <div id=\"frm_desc_field_n6fgo\" class=\"frm_description\">Dites-nous en plus !<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_165_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* :\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_165-0\">\t\t\t<label  for=\"field_l8xhl-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-0\" value=\"Couvre-poche en jean\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Couvre-poche en jean<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-1\">\t\t\t<label  for=\"field_l8xhl-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-1\" value=\"Couvre-poche en dentelle\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Couvre-poche en dentelle<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-10\">\t\t\t<label  for=\"field_l8xhl-10\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-10\" value=\"Couvre poche noir\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Couvre poche noir<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-11\">\t\t\t<label  for=\"field_l8xhl-11\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-11\" value=\"Couvre poche beige\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Couvre poche beige<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-2\">\t\t\t<label  for=\"field_l8xhl-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-2\" value=\"Filet confort\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Filet confort<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-3\">\t\t\t<label  for=\"field_l8xhl-3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-3\" value=\"Ciseaux courb\u00e9s\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Ciseaux courb\u00e9s<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-6\">\t\t\t<label  for=\"field_l8xhl-6\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-6\" value=\"Sacs poubelle\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Sacs poubelle<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-7\">\t\t\t<label  for=\"field_l8xhl-7\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-7\" value=\"Trousse de voyage (comprenant ciseaux courb\u00e9s, sacs poubelle, miroir, stomim\u00e8tre)\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Trousse de voyage (comprenant ciseaux courb\u00e9s, sacs poubelle, miroir, stomim\u00e8tre)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-8\">\t\t\t<label  for=\"field_l8xhl-8\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-8\" value=\"Pass voyage et carte d&#039;acc\u00e8s aux toilettes\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> Pass voyage et carte d'acc\u00e8s aux toilettes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_165-9\">\t\t\t<label  for=\"field_l8xhl-9\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[165]\" id=\"field_l8xhl-9\" value=\"J&#039;ai d\u00e9j\u00e0 re\u00e7u mon accessoire de bienvenue\"\n\t\t data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile l\u2019outil suivant* : est non valide\"   \/> J'ai d\u00e9j\u00e0 re\u00e7u mon accessoire de bienvenue<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_183_container\" class=\"frm_form_field  frm_html_container form-field\">* Offre limit\u00e9e \u00e0 un accessoire par personne par adresse postale<\/div>\n<div id=\"frm_field_148_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants : \r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-1\">\t\t\t<label  for=\"field_zn1bx-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-1\" value=\"Vivre avec une stomie\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Vivre avec une stomie<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-2\">\t\t\t<label  for=\"field_zn1bx-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-2\" value=\"Stomie et grossesse\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Stomie et grossesse<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-4\">\t\t\t<label  for=\"field_zn1bx-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-4\" value=\"Sexualit\u00e9\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Sexualit\u00e9<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-5\">\t\t\t<label  for=\"field_zn1bx-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-5\" value=\"Personne aidante\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Personne aidante<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-6\">\t\t\t<label  for=\"field_zn1bx-6\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-6\" value=\"Stomie et Sport\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Stomie et Sport<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-7\">\t\t\t<label  for=\"field_zn1bx-7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-7\" value=\"Expliquer \u00e0 l&#039;entourage\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Expliquer \u00e0 l'entourage<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-8\">\t\t\t<label  for=\"field_zn1bx-8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-8\" value=\"Trucs et astuces\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Trucs et astuces<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_148-9\">\t\t\t<label  for=\"field_zn1bx-9\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[148][]\" id=\"field_zn1bx-9\" value=\"Di\u00e9t\u00e9tique\"  data-invmsg=\"Je souhaite recevoir gratuitement \u00e0 mon domicile les documents suivants :  est non valide\"   \/> Di\u00e9t\u00e9tique<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_166_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <label  class=\"frm_primary_label\">Je m\u2019inscris \u00e0 la prochaine conf\u00e9rence en ligne (gratuit \u2013 inscription obligatoire)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_166-0\">\t\t\t<label  for=\"field_zoej9-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[166]\" id=\"field_zoej9-0\" value=\"Oui\"\n\t\t data-invmsg=\"Je m\u2019inscris \u00e0 la prochaine conf\u00e9rence en ligne (gratuit \u2013 inscription obligatoire) est non valide\"   \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_166-1\">\t\t\t<label  for=\"field_zoej9-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[166]\" id=\"field_zoej9-1\" value=\"Non\"\n\t\t data-invmsg=\"Je m\u2019inscris \u00e0 la prochaine conf\u00e9rence en ligne (gratuit \u2013 inscription obligatoire) est non valide\"   \/> Non<\/label><\/div>\n<\/div>\r\n    <div id=\"frm_desc_field_zoej9\" class=\"frm_description\">La date, la th\u00e9matique et l\u2019horaire seront communiqu\u00e9s ult\u00e9rieurement.\r\nD\u00e9couvrez tous les \u00e9v\u00e8nements dans la rubrique <a href=\"https:\/\/www.vivreplushollister.com\/stomie\/agenda\/\">Agenda<\/a> !<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_149_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio frm_other_container\">\r\n    <label  class=\"frm_primary_label\">Comment avez-vous connu Vivre + ?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-0\">\t\t\t<label  for=\"field_lrgo3-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][]\" id=\"field_lrgo3-0\" value=\"Professionnels de sant\u00e9\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> Professionnels de sant\u00e9<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-1\">\t\t\t<label  for=\"field_lrgo3-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][]\" id=\"field_lrgo3-1\" value=\"Salons grand public (Autonomic, Handica...)\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> Salons grand public (Autonomic, Handica...)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-2\">\t\t\t<label  for=\"field_lrgo3-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][]\" id=\"field_lrgo3-2\" value=\"Connaissance\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> Connaissance<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-3\">\t\t\t<label  for=\"field_lrgo3-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][]\" id=\"field_lrgo3-3\" value=\"Hollister (courrier, t\u00e9l\u00e9phone, packaging)\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> Hollister (courrier, t\u00e9l\u00e9phone, packaging)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-4\">\t\t\t<label  for=\"field_lrgo3-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][]\" id=\"field_lrgo3-4\" value=\"R\u00e9seaux sociaux (Facebook, Instagram...)\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> R\u00e9seaux sociaux (Facebook, Instagram...)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-5\">\t\t\t<label  for=\"field_lrgo3-5\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][]\" id=\"field_lrgo3-5\" value=\"Site internet Hollister\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> Site internet Hollister<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-other_7\">\t\t\t<label  for=\"field_lrgo3-other_7\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][other_7]\" id=\"field_lrgo3-other_7\" value=\"Moteur de recherche, pr\u00e9cisez les mots cl\u00e9s :\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> Moteur de recherche, pr\u00e9cisez les mots cl\u00e9s :<\/label><label for=\"field_lrgo3-other_7-otext\" class=\"frm_screen_reader frm_hidden\">Moteur de recherche, pr\u00e9cisez les mots cl\u00e9s :<\/label><input type=\"text\" id=\"field_lrgo3-other_7-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][149][other_7]\" value=\"\" \/><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_149-other_8\">\t\t\t<label  for=\"field_lrgo3-other_8\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[149][other_8]\" id=\"field_lrgo3-other_8\" value=\"Autre\"  data-invmsg=\"Comment avez-vous connu Vivre + ? est non valide\"   \/> Autre<\/label><label for=\"field_lrgo3-other_8-otext\" class=\"frm_screen_reader frm_hidden\">Autre<\/label><input type=\"text\" id=\"field_lrgo3-other_8-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][149][other_8]\" value=\"\" \/><\/div>\n<\/div>\r\n    <div id=\"frm_desc_field_lrgo3\" class=\"frm_description\">Dites-nous en plus !<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_154_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_rjexu\" class=\"frm_primary_label\">Une question ? Votre conseill\u00e8re Vivre+ est d\u00e9j\u00e0 \u00e0 votre service !\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[154]\" id=\"field_rjexu\" rows=\"5\"  data-invmsg=\"Une question ? Votre conseill\u00e8re Vivre+ est d\u00e9j\u00e0 \u00e0 votre service ! est non valide\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_190_container\" class=\"frm_form_field  frm_html_container form-field\">\n<p>Quel niveau de service voulez-vous chez Hollister ?<\/p>\n<p>Il est \u00e0 votre discr\u00e9tion de choisir le niveau de service dont vous avez besoin et de partager vos renseignements personnels avec nous dans la mesure requise. En cochant l\u2019une ou les cases, je consens au traitement des mes donn\u00e9es personnelles pour l\u2019une ou les finalit\u00e9s ci-dessous.<\/p>\n<p>Cochez les cases correspondant \u00e0 vos choix :\u00a0<\/p>\n<\/div>\n<div id=\"frm_field_184_container\" class=\"frm_form_field form-field  frm_none_container vertical_radio\">\r\n    <div  id=\"field_b4hlt_label\" class=\"frm_primary_label\">Quel niveau de service voulez-vous chez Hollister ?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_b4hlt_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_184-0\">\t\t\t<label  for=\"field_b4hlt-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[184][]\" id=\"field_b4hlt-0\" value=\"&lt;b&gt; Adh\u00e9sion au service de l\u2019utilisateur final &lt;\/b&gt;&lt;br&gt; Dans le but de m\u2019inscrire \u00e0 Vivre+ pour les patients\/aidants\"  data-invmsg=\"Quel niveau de service voulez-vous chez Hollister ? est non valide\"   \/> <b> Adh\u00e9sion au service de l\u2019utilisateur final <\/b><br> Dans le but de m\u2019inscrire \u00e0 Vivre+ pour les patients\/aidants<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_184-1\">\t\t\t<label  for=\"field_b4hlt-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[184][]\" id=\"field_b4hlt-1\" value=\"&lt;b&gt;Demande d&#039;\u00e9chantillons&lt;\/b&gt;&lt;br&gt; Dans le but de traiter, d\u2019ex\u00e9cuter et de communiquer avec moi au sujet de la demande d\u2019\u00e9chantillon de produit que je demande.\"  data-invmsg=\"Quel niveau de service voulez-vous chez Hollister ? est non valide\"   \/> <b>Demande d'\u00e9chantillons<\/b><br> Dans le but de traiter, d\u2019ex\u00e9cuter et de communiquer avec moi au sujet de la demande d\u2019\u00e9chantillon de produit que je demande.<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_184-2\">\t\t\t<label  for=\"field_b4hlt-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[184][]\" id=\"field_b4hlt-2\" value=\"&lt;b&gt;Marketing direct&lt;\/b&gt;&lt;br&gt;Dans le but de recevoir des informations sur des produits, des promotions et d\u2019autres campagnes de marketing direct.\"  data-invmsg=\"Quel niveau de service voulez-vous chez Hollister ? est non valide\"   \/> <b>Marketing direct<\/b><br>Dans le but de recevoir des informations sur des produits, des promotions et d\u2019autres campagnes de marketing direct.<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_184-3\">\t\t\t<label  for=\"field_b4hlt-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[184][]\" id=\"field_b4hlt-3\" value=\"&lt;b&gt; Feedback\/Retour d\u2019exp\u00e9rience &lt;\/b&gt;&lt;br&gt;Dans le but de participer aux programmes de retour d\u2019exp\u00e9rience de Hollister.\"  data-invmsg=\"Quel niveau de service voulez-vous chez Hollister ? est non valide\"   \/> <b> Feedback\/Retour d\u2019exp\u00e9rience <\/b><br>Dans le but de participer aux programmes de retour d\u2019exp\u00e9rience de Hollister.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_186_container\" class=\"frm_form_field  frm_html_container form-field\">\n<p><span style=\"font-size: 13px;\">* Donn\u00e9e(s) dont la fourniture est obligatoire. Votre consentement est facultatif et vous avez le droit de le retirer \u00e0 tout moment. Pour retirer votre consentement ou apporter des modifications \u00e0 vos pr\u00e9f\u00e9rences de communication, contactez-nous par courrier \u00e0 Assistance Conseil, Tour Franklin, 100\/101 Terrasse Boieldieu, 92042 Paris la D\u00e9fense ou par email \u00e0 assistance.conseil@hollister.com ou au num\u00e9ro vert 0800 47 92 67, appels et service gratuits. Ce retrait n\u2019aura d\u2019effet qu\u2019\u00e0 l\u2019avenir, c\u2019est-\u00e0-dire que le retrait de votre consentement n\u2019affecte pas la lic\u00e9it\u00e9 du traitement des donn\u00e9es et de la divulgation des informations avant le retrait de votre consentement. Vous retrouverez plus de d\u00e9tails concernant le traitement de vos donn\u00e9es dans notre brochure Vivre+ disponible sous l\u2019onglet Club.<\/span><\/p>\n<p><span style=\"font-size: 13px;\">*Adh\u00e9sion au service Vivre+ pour les patients \/ les aidants : Afin d\u2019adh\u00e9rer \u00e0 Vivre +, un programme gratuit de service aux patients\/aidants, et de recevoir les avantages li\u00e9s \u00e0 cette adh\u00e9sion, j\u2019accepte le traitement de mon identification personnelle, de mes pr\u00e9f\u00e9rences de communication, de mes informations de sant\u00e9, des informations sur les produits, des informations de tiers, des informations de transaction et des d\u00e9tails de ma demande par Hollister, y compris les soci\u00e9t\u00e9s de son groupe (La liste de ces soci\u00e9t\u00e9s est disponible sur notre site internet \u00e0 l\u2019adresse <a href=\"https:\/\/www.hollister.fr\/fr-fr\/hollistergroupcompanies\">https:\/\/www.hollister.fr\/fr-fr\/hollistergroupcompanies<\/a>) et sa soci\u00e9t\u00e9 de service affili\u00e9e, le cas \u00e9ch\u00e9ant. Je comprends que ces services sont gratuits et qu\u2019il n\u2019y a aucune obligation d\u2019acheter quoi que ce soit pour les recevoir. Je comprends que je n\u2019ai aucune obligation de participer \u00e0 tout ou partie des avantages li\u00e9s \u00e0 l\u2019adh\u00e9sion applicables, comme une assistance pour identifier les options de fournisseur de produits et la r\u00e9ception d\u2019\u00e9chantillons de produits et d\u2019autres articles gratuits. Je comprends que Hollister, y compris les soci\u00e9t\u00e9s de son groupe et son fournisseur de produits affili\u00e9, peuvent communiquer avec moi concernant les services aux patients\/aidants, ou dans le cadre des avantages associ\u00e9s \u00e0 l\u2019adh\u00e9sion, en utilisant les coordonn\u00e9es (adresse postale, e-mail, t\u00e9l\u00e9phone et SMS) que j\u2019ai fournies. Hollister se r\u00e9serve le droit de modifier le programme de service aux patients\/ aidants \u00e0 tout moment.<\/span><\/p>\n<p><span style=\"font-size: 13px;\"><a href=\"https:\/\/vivreplushollister.com\/Mentions-RGPD-Vivre-Hollister-2025.pdf\" target=\"_blank\" rel=\"noopener\">\u2192 Mentions RGPD Vivre+ Hollister<\/a><\/span><\/p>\n<\/div>\n<div id=\"frm_field_162_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"g-recaptcha-response\" class=\"frm_primary_label\">Anti-spam\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div  id=\"field_uj6id\" class=\"g-recaptcha\" data-sitekey=\"6LfWr6ceAAAAAJsSnISESW2XzB4SuXg32HeH09fM\" data-size=\"normal\" data-theme=\"light\"><\/div>\r\n    \r\n    \r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[84]\" id=\"field_d7cmi\" value=\"\" data-frmval=\"\"\/>\n<div id=\"frm_field_187_container\" class=\"frm_form_field form-field \">\n\t<div class=\"frm_submit\">\r\n\r\n<input type=\"submit\" value=\"Envoyer\"  class=\"frm_final_submit\" formnovalidate=\"formnovalidate\" \/>\r\n<img decoding=\"async\" class=\"frm_ajax_loading\" src=\"https:\/\/www.vivreplushollister.com\/stomie\/wp-content\/plugins\/formidable\/images\/ajax_loader.gif\" alt=\"Envoi\"\/>\r\n\r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_192_container\">\n\t\t\t<label for=\"field_y3aof\" >\n\t\t\t\tSi vous \u00eates un humain, ne remplissez pas ce champ.\t\t\t<\/label>\n\t\t\t<input  id=\"field_y3aof\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[192]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"frm_register[email]\" value=\"66\"\/>\n<input type=\"hidden\" name=\"frm_register[username]\" value=\"-1\"\/>\n<input type=\"hidden\" name=\"frm_register[password]\" value=\"161\"\/>\n<input type=\"hidden\" name=\"frm_register[subsite_title]\" value=\"username\"\/>\n<input type=\"hidden\" name=\"frm_register[subsite_domain]\" value=\"blog_title\"\/>\n<input name=\"frm_state\" type=\"hidden\" value=\"2\/vhfcIHgOy72EzV9X2+HWcQCH0XRmzQkYblrhj4tEsWu9S13JaZi10iN3HtAOpS\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n\n","protected":false},"excerpt":{"rendered":"<p>QUEL NIVEAU DE SERVICES SOUHAITEZ VOUS\u00a0?<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_price":"","_stock":"","_tribe_ticket_header":"","_tribe_default_ticket_provider":"","_tribe_ticket_capacity":"0","_ticket_start_date":"","_ticket_end_date":"","_tribe_ticket_show_description":"","_tribe_ticket_show_not_going":false,"_tribe_ticket_use_global_stock":"","_tribe_ticket_global_stock_level":"","_global_stock_mode":"","_global_stock_cap":"","_tribe_rsvp_for_event":"","_tribe_ticket_going_count":"","_tribe_ticket_not_going_count":"","_tribe_tickets_list":"[]","_tribe_ticket_has_attendee_info_fields":false,"footnotes":""},"class_list":["post-166","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.8 - 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