{"id":20,"date":"2026-03-13T08:26:13","date_gmt":"2026-03-13T07:26:13","guid":{"rendered":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/adressage-patient\/"},"modified":"2026-03-13T08:26:13","modified_gmt":"2026-03-13T07:26:13","slug":"adressage-patient","status":"publish","type":"page","link":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/","title":{"rendered":"Formulaire d&rsquo;adressage patient"},"content":{"rendered":"<div class=\"snpa-layout snpa-layout--with-sidebar\"><div class=\"snpa-layout-aside\">        <aside class=\"snpa-sidebar\">\n\n            <!-- \u2500\u2500 Barre burger (mobile uniquement) \u2500\u2500 -->\n            <div class=\"snpa-sidebar-burger\" role=\"button\" aria-expanded=\"false\" aria-controls=\"snpa-sb-content\" tabindex=\"0\">\n                <div class=\"snpa-sidebar-burger-left\">\n                                                                    <a href=\"https:\/\/somno.plus\/\" target=\"_blank\" rel=\"noopener\" onclick=\"event.stopPropagation()\">\n                            <img decoding=\"async\" src=\"http:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-content\/uploads\/2026\/03\/Logo-Somnoplus.png\"\n                                 alt=\"Logo\"\n                                 class=\"snpa-sidebar-burger-logo\">\n                        <\/a>\n                                                                                <\/div>\n                <div class=\"snpa-sidebar-burger-icon\" aria-hidden=\"true\">\n                    <span><\/span><span><\/span><span><\/span>\n                <\/div>\n            <\/div>\n\n            <!-- \u2500\u2500 Contenu d\u00e9roulant \u2500\u2500 -->\n            <div class=\"snpa-sidebar-content\" id=\"snpa-sb-content\">\n\n                        <div class=\"snpa-sidebar-logo\">\n                                <a href=\"https:\/\/somno.plus\/\" target=\"_blank\" rel=\"noopener\" class=\"snpa-sb-logo-link\">\n                    <img decoding=\"async\" src=\"http:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-content\/uploads\/2026\/03\/Logo-Somnoplus.png\"\n                         alt=\"Logo\">\n                <\/a>\n                            <\/div>\n            \n            \n            <ul class=\"snpa-sidebar-contacts\">\n\n                                <li class=\"snpa-sidebar-item snpa-sidebar-item--tel\">\n                    <span class=\"snpa-sb-icon\"><img decoding=\"async\" src=\"https:\/\/cdn.jsdelivr.net\/gh\/twitter\/twemoji@14\/assets\/svg\/1f4de.svg\" alt=\"\" aria-hidden=\"true\" class=\"snpa-twemoji\" style=\"width:18px;height:18px;vertical-align:-0.125em;display:inline-block;\" loading=\"lazy\"><\/span>\n                    <a href=\"tel:0467622277\">\n                        04 67 62 22 77                    <\/a>\n                <\/li>\n                \n                                <li class=\"snpa-sidebar-item snpa-sidebar-item--email\">\n                    <span class=\"snpa-sb-icon\"><img decoding=\"async\" src=\"https:\/\/cdn.jsdelivr.net\/gh\/twitter\/twemoji@14\/assets\/svg\/2709.svg\" alt=\"\" aria-hidden=\"true\" class=\"snpa-twemoji\" style=\"width:18px;height:18px;vertical-align:-0.125em;display:inline-block;\" loading=\"lazy\"><\/span>\n                    <a href=\"mailto:contact@somno.plus\">\n                        contact@somno.plus                    <\/a>\n                <\/li>\n                \n                                <li class=\"snpa-sidebar-item snpa-sidebar-item--adresse\">\n                    <span class=\"snpa-sb-icon\"><img decoding=\"async\" src=\"https:\/\/cdn.jsdelivr.net\/gh\/twitter\/twemoji@14\/assets\/svg\/1f4cd.svg\" alt=\"\" aria-hidden=\"true\" class=\"snpa-twemoji\" style=\"width:18px;height:18px;vertical-align:-0.125em;display:inline-block;\" loading=\"lazy\"><\/span>\n                                            <a href=\"https:\/\/maps.app.goo.gl\/EHanBctnrvqnvqak7\" target=\"_blank\" rel=\"noopener\">\n                            220 Bd P\u00e9n\u00e9lope<br \/>\r\n34000 Montpellier                        <\/a>\n                                    <\/li>\n                \n            <\/ul>\n\n                        <ul class=\"snpa-sidebar-contacts\" style=\"padding-top:0;border-top:none;\">\n            <li class=\"snpa-sidebar-item snpa-sidebar-item--horaires\">\n                <span class=\"snpa-sb-icon\"><img decoding=\"async\" src=\"https:\/\/cdn.jsdelivr.net\/gh\/twitter\/twemoji@14\/assets\/svg\/1f552.svg\" alt=\"\" aria-hidden=\"true\" class=\"snpa-twemoji\" style=\"width:18px;height:18px;vertical-align:-0.125em;display:inline-block;\" loading=\"lazy\"><\/span>\n                <div>\n                                    <div>Lun\u2013Ven : 8h30\u201318h<\/div>\n                                    <div>Sam : 9h\u201312h<\/div>\n                                <\/div>\n            <\/li>\n            <\/ul>\n            \n\n\n            <div class=\"snpa-sidebar-footer\">\n                <span class=\"snpa-sb-icon snpa-sb-icon--sm\"><img decoding=\"async\" src=\"https:\/\/cdn.jsdelivr.net\/gh\/twitter\/twemoji@14\/assets\/svg\/1f512.svg\" alt=\"\" aria-hidden=\"true\" class=\"snpa-twemoji\" style=\"width:16px;height:16px;vertical-align:-0.125em;display:inline-block;\" loading=\"lazy\"><\/span>\n                Messagerie MSSant\u00e9 s\u00e9curis\u00e9e\n            <\/div>\n\n            <\/div><!-- \/.snpa-sidebar-content -->\n\n        <\/aside>\n        <\/div><div class=\"snpa-layout-main\">        <div class=\"snpa-wrap snpa-patient\" id=\"snpa-form-patient\">\n\n            <div class=\"snpa-intro\">\n                <h2 class=\"snpa-title\">Demande de prise en charge<\/h2>\n                <p class=\"snpa-subtitle\">Vous souffrez de troubles du sommeil et souhaitez \u00eatre pris en charge ? Remplissez ce formulaire et nous vous rappellerons dans les meilleurs d\u00e9lais.<\/p>\n            <\/div>\n\n            <div class=\"snpa-form-body\">\n            <form class=\"snpa-form\" id=\"snpa-patient-form\" novalidate data-form-type=\"patient\">\n\n                <div class=\"snpa-hp\" aria-hidden=\"true\" tabindex=\"-1\" style=\"position:absolute;left:-9999px;width:1px;height:1px;overflow:hidden;\">\n                <label for=\"snpa_website\">Ne pas remplir<\/label>\n                <input type=\"text\" id=\"snpa_website\" name=\"snpa_website\" value=\"\" autocomplete=\"off\" tabindex=\"-1\">\n            <\/div>\n            <input type=\"hidden\" name=\"snpa_token\" value=\"MTc3OTE3MTE1NXw3YjE3NWQxMzI1YzZiODNkZDI4ODdmNzMxMmZhYmI0ODM3MGU4MTVhZjBlMGVkMTNjNDYyYTkwZDNlNWVmN2Yy\">\n                <div class=\"snpa-row\">\n                    <div class=\"snpa-field snpa-required\">\n                        <label for=\"snpa_pat_nom\">Nom <span class=\"snpa-req-star\">*<\/span><\/label>\n                        <input type=\"text\" id=\"snpa_pat_nom\" name=\"nom\" autocomplete=\"family-name\"\n                               placeholder=\"DUPONT\" required maxlength=\"100\">\n                        <span class=\"snpa-error\" role=\"alert\"><\/span>\n                    <\/div>\n                    <div class=\"snpa-field snpa-required\">\n                        <label for=\"snpa_pat_prenom\">Pr\u00e9nom <span class=\"snpa-req-star\">*<\/span><\/label>\n                        <input type=\"text\" id=\"snpa_pat_prenom\" name=\"prenom\" autocomplete=\"given-name\"\n                               placeholder=\"Marie\" required maxlength=\"100\">\n                        <span class=\"snpa-error\" role=\"alert\"><\/span>\n                    <\/div>\n                <\/div>\n\n                <div class=\"snpa-row\">\n                    <div class=\"snpa-field snpa-required\">\n                        <label for=\"snpa_pat_ddn\">Date de naissance <span class=\"snpa-req-star\">*<\/span><\/label>\n                        <input type=\"date\" id=\"snpa_pat_ddn\" name=\"ddn\" required                               max=\"2026-05-19\">\n                        <span class=\"snpa-error\" role=\"alert\"><\/span>\n                    <\/div>\n                    <div class=\"snpa-field snpa-required\">\n                        <label for=\"snpa_pat_tel\">T\u00e9l\u00e9phone <span class=\"snpa-req-star\">*<\/span><\/label>\n                        <input type=\"tel\" id=\"snpa_pat_tel\" name=\"tel\" autocomplete=\"tel\"\n                               placeholder=\"0612345678\" required pattern=\"\\d{10}\" maxlength=\"10\" inputmode=\"numeric\">\n                        <span class=\"snpa-error\" role=\"alert\"><\/span>\n                    <\/div>\n                <\/div>\n\n                <div class=\"snpa-row\">\n                    <div class=\"snpa-field\">\n                        <label for=\"snpa_pat_email\">Adresse email <span class=\"snpa-optional\">(facultatif)<\/span> <\/label>\n                        <input type=\"email\" id=\"snpa_pat_email\" name=\"email\" autocomplete=\"email\"\n                               placeholder=\"marie.dupont@email.fr\"  maxlength=\"200\">\n                        <span class=\"snpa-error\" role=\"alert\"><\/span>\n                    <\/div>\n                    <div class=\"snpa-field snpa-required\">\n                        <label for=\"snpa_pat_nss\">\n                            Num\u00e9ro de S\u00e9curit\u00e9 Sociale <span class=\"snpa-req-star\">*<\/span>                            <button type=\"button\" class=\"snpa-tooltip-btn\" aria-label=\"Pourquoi ce num\u00e9ro ?\">?<\/button>\n                            <span class=\"snpa-tooltip-content\">Votre num\u00e9ro de s\u00e9curit\u00e9 sociale (13 chiffres) est n\u00e9cessaire pour cr\u00e9er votre dossier.<\/span>\n                        <\/label>\n                        <input type=\"text\" id=\"snpa_pat_nss\" name=\"nss\"\n                               placeholder=\"1 80 01 75 XXX XXX\" required                               pattern=\"\\d{13}\" maxlength=\"13\" inputmode=\"numeric\">\n                        <span class=\"snpa-error\" role=\"alert\"><\/span>\n                    <\/div>\n                <\/div>\n\n                <div class=\"snpa-field\">\n                    <label for=\"snpa_pat_plainte\">D\u00e9crivez votre situation <span class=\"snpa-optional\">(facultatif)<\/span> <\/label>\n                    <textarea id=\"snpa_pat_plainte\" name=\"plainte\" rows=\"4\"\n                              placeholder=\"D\u00e9crivez vos troubles\u2026\"                               maxlength=\"2000\"><\/textarea>\n                    <span class=\"snpa-char-count\"><span class=\"snpa-count\">0<\/span>\/2000<\/span>\n                <\/div>\n\n                <!-- Consentement inline -->\n                <div class=\"snpa-field snpa-field--checkbox snpa-required\">\n                    <label class=\"snpa-checkbox-label snpa-checkbox-label--inline\">\n                        <input type=\"checkbox\" name=\"consentement\" id=\"snpa_consentement\" required>\n                        <span class=\"snpa-checkbox-custom\"><\/span>\n                        <span class=\"snpa-checkbox-text\">J'accepte que mes informations soient transmises \u00e0 l'\u00e9quipe dans le cadre de ma demande de prise en charge.  <span class=\"snpa-req-star\">*<\/span><\/span>\n                    <\/label>\n                    <span class=\"snpa-error\" role=\"alert\"><\/span>\n                <\/div>\n\n                <div class=\"snpa-actions\">\n                    <button type=\"submit\" class=\"snpa-btn snpa-btn--primary\">\n                        <span class=\"snpa-btn-text\">Envoyer ma demande<\/span>\n                        <span class=\"snpa-btn-spinner\" aria-hidden=\"true\"><\/span>\n                    <\/button>\n                <\/div>\n                <p class=\"snpa-rgpd-note\">\n                    <img decoding=\"async\" src=\"https:\/\/cdn.jsdelivr.net\/gh\/twitter\/twemoji@14\/assets\/svg\/1f512.svg\" alt=\"\" aria-hidden=\"true\" class=\"snpa-twemoji\" style=\"width:18px;height:18px;vertical-align:-0.125em;display:inline-block;\" loading=\"lazy\"> Les donn\u00e9es sont transmises par messagerie m\u00e9dicale s\u00e9curis\u00e9e (MSSant\u00e9) et ne sont pas conserv\u00e9es sur ce site.\n                <\/p>\n\n            <\/form>\n            <\/div>\n\n            <div class=\"snpa-success\" id=\"snpa-patient-success\" hidden>\n                <div class=\"snpa-success-icon\"><img decoding=\"async\" src=\"https:\/\/cdn.jsdelivr.net\/gh\/twitter\/twemoji@14\/assets\/svg\/2705.svg\" alt=\"\" aria-hidden=\"true\" class=\"snpa-twemoji\" style=\"width:18px;height:18px;vertical-align:-0.125em;display:inline-block;\" loading=\"lazy\"><\/div>\n                <h3>Votre demande a bien \u00e9t\u00e9 re\u00e7ue !<\/h3>\n                <p>Un membre de notre \u00e9quipe vous rappellera dans les meilleurs d\u00e9lais, g\u00e9n\u00e9ralement sous <strong>48 \u00e0 72 heures ouvr\u00e9es<\/strong>.<\/p>\n            <\/div>\n\n            <div class=\"snpa-error-global\" id=\"snpa-patient-error\" hidden role=\"alert\">\n                <strong>Une erreur est survenue.<\/strong> Veuillez r\u00e9essayer ou nous contacter directement.\n            <\/div>\n\n        <\/div>\n        <\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-20","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-json\/wp\/v2\/pages\/20","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-json\/wp\/v2\/comments?post=20"}],"version-history":[{"count":0,"href":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-json\/wp\/v2\/pages\/20\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.adcomplus.fr\/MonEspaceSante\/wp-json\/wp\/v2\/media?parent=20"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}