{"id":10647,"date":"2015-07-22T15:17:54","date_gmt":"2015-07-22T13:17:54","guid":{"rendered":"http:\/\/www.dalpasso.it\/fr\/contatti\/per-richiedere-le-vostre-immagini\/modulo-per-pazienti-maggiorenni\/"},"modified":"2015-11-19T14:45:44","modified_gmt":"2015-11-19T13:45:44","slug":"formulaire-pour-patients-majeurs","status":"publish","type":"page","link":"https:\/\/www.dalpasso.it\/fr\/contacts\/pour-demander-vos-images\/formulaire-pour-patients-majeurs\/","title":{"rendered":"Formulaire pour patients majeurs"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row][vc_column width=\u00a0\u00bb5\/6&Prime; css=\u00a0\u00bb.vc_custom_1442915850638{padding: 20px !important;background-color: #b8e3f2 !important;}\u00a0\u00bb offset=\u00a0\u00bbvc_col-lg-7 vc_col-md-offset-2 vc_col-md-8 vc_col-sm-offset-1&Prime;][vc_column_text]<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f10649-o1\" lang=\"it-IT\" dir=\"ltr\" data-wpcf7-id=\"10649\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/10647#wpcf7-f10649-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Modulo di contatto\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"10649\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"it_IT\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f10649-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<p>Je soussign\u00e9(e) *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nome\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nome\" \/><\/span>\n<\/p>\n<p>N\u00e9(e) \u00e0 *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"citta\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"citta\" \/><\/span>\n<\/p>\n<p>le (jj\/mm\/aaaa)*\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"datanascita\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"datanascita\" \/><\/span>\n<\/p>\n<p>R\u00e9sidant \u00e0 *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"residenza\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"residenza\" \/><\/span>\n<\/p>\n<p>Adresse *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"indirizzo\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"indirizzo\" \/><\/span>\n<\/p>\n<p>Courriel*\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"e-mail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"e-mail\" \/><\/span>\n<\/p>\n<hr \/>\n<h4>D\u00c9CLARE\n<\/h4>\n<ul>\n\t<li>\n\t\t<p>\u00eatre porteur d'une proth\u00e8se oculaire appliqu\u00e9e dans un centre de la soci\u00e9t\u00e9 Dalpasso S.r.l. \u00e9tablie \u00e0 Reggio Emilia, via Turri n\u00b010 *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro1\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">OUI<\/span><input type=\"checkbox\" name=\"dichiaro1\" value=\"OUI\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NON<\/span><input type=\"checkbox\" name=\"dichiaro1\" value=\"NON\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>\u00eatre au courant des sanctions encourues contre toute personne fournissant de fausses donn\u00e9es ou informations *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro2\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">OUI<\/span><input type=\"checkbox\" name=\"dichiaro2\" value=\"OUI\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NON<\/span><input type=\"checkbox\" name=\"dichiaro2\" value=\"NON\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>\u00eatre inform\u00e9 par Dalpasso S.r.l sur les normes qui r\u00e9gissent le traitement des donn\u00e9es sensibles conform\u00e9ment au d\u00e9cret l\u00e9gislatif italien 196\/2003 *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro3\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">OUI<\/span><input type=\"checkbox\" name=\"dichiaro3\" value=\"OUI\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NON<\/span><input type=\"checkbox\" name=\"dichiaro3\" value=\"NON\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>j'exon\u00e8re Dalpasso S.r.l de toute responsabilit\u00e9 quant \u00e0 la pr\u00e9sente demande *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dichiaro4\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">OUI<\/span><input type=\"checkbox\" name=\"dichiaro4\" value=\"OUI\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">NON<\/span><input type=\"checkbox\" name=\"dichiaro4\" value=\"NON\" \/><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/li>\n<\/ul>\n<hr \/>\n<h4>DEMANDE\n<\/h4>\n<p>L'envoi de la copie des images photographiques num\u00e9riques prises et conserv\u00e9es dans les archives magn\u00e9tiques de l'entreprise Dalpasso S.r.l.\n<\/p>\n<p style=\"margin-top:0.5em;\">Dates des clich\u00e9s photographiques: *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"descrizionefoto\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"descrizionefoto\"><\/textarea><\/span>\n<\/p>\n<p>A cette fin, je soussign\u00e9(e) choisi le support suivant pour les images demand\u00e9es:\n<\/p>\n<ul>\n\t<li>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invio\"><span class=\"wpcf7-form-control wpcf7-checkbox inline\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"invio[]\" value=\"\" \/><span class=\"wpcf7-list-item-label\"><\/span><\/span><\/span><\/span> CD Rom \u00e0 envoyer par courrier postal, frais d'envoi \u00e0 la charge du destinataire *\n\t\t<\/p>\n\t<\/li>\n\t<li>\n\t\t<p>Envoi par courrier \u00e9lectronique \u00e0 l'adresse courriel suivante: *\n\t\t<\/p>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invio_email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"invio_email\" \/><\/span>\n\t\t<\/p>\n\t<\/li>\n<\/ul>\n<p>Je m'engage \u00e0 fournir rapidement la photocopie d'un document d'identit\u00e9 du requ\u00e9rant par: *\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"invio_documento\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Fax<\/span><input type=\"checkbox\" name=\"invio_documento\" value=\"Fax\" \/><\/label><\/span><span class=\"wpcf7-list-item\"><label><span class=\"wpcf7-list-item-label\">Courriel<\/span><input type=\"checkbox\" name=\"invio_documento\" value=\"Courriel\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Courrier postal<\/span><input type=\"checkbox\" name=\"invio_documento\" value=\"Courrier postal\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<hr \/>\n<h4>VIE PRIV\u00c9E\n<\/h4>\n<p><small>Je soussign\u00e9(e) prends acte des <a href=\"#0\">informations<\/a> en vertu de l'article 13 du D\u00e9cret l\u00e9gislatif italien 196\/2003, et consens au traitement de mes donn\u00e9es personnelles aux fins indiqu\u00e9es ainsi qu'au fait qu'elles puissent faire l'objet de communication aux entit\u00e9s et aux fins d\u00e9clar\u00e9es.<\/small>\n<\/p>\n<p><label>J'autorise: <span class=\"wpcf7-form-control-wrap\" data-name=\"consenso\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"consenso\" value=\"1\" aria-invalid=\"false\" \/><\/span><\/span><\/span><\/label>\n<\/p>\n<div style=\"margin:1.5em 0\">\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t<\/p>\n<\/div><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<p>[\/vc_column_text][\/vc_column][\/vc_row]<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column width=\u00a0\u00bb5\/6&Prime; css=\u00a0\u00bb.vc_custom_1442915850638{padding: 20px !important;background-color: #b8e3f2 !important;}\u00a0\u00bb 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