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calebasse / calebasse / dossiers / templates / dossiers / patientcontact_new.html @ 158b10a6

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{% load widget_tweaks %}
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<form action="{{ request.get_full_path }}" enctype="multipart/form-data" method="post">
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  {% csrf_token %}
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  <table>
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    <tbody>
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      <tr>
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        <td>
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          {{ form.first_name.label_tag }} :<br>
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          {{ form.first_name }}
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          {{ form.first_name.errors }}
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        </td>
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        <td>
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          {{ form.last_name.label_tag }} :<br>
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          {{ form.last_name }}
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          {{ form.last_name.errors }}
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        </td>
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        <td>
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          {{ form.gender.label_tag }} :<br>
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          {{ form.gender }}
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          {{ form.gender.errors }}
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        </td>
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      </tr>
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      <tr>
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        <td>
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          {{ form.birthdate.label_tag }} :<br>
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          {{ form.birthdate }}
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          {{ form.birthdate.errors }}
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        </td>
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         <td>
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          {{ form.birthplace.label_tag }} :<br>
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          {{ form.birthplace }}
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          {{ form.birthplace.errors }}
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        </td>
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        <td>
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          {{ form.twinning_rank.label_tag }} :<br>
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          {{ form.twinning_rank }}
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          {{ form.twinning_rank.errors }}
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        </td>
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      </tr>
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      <tr>
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         <td>
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          {{ form.parente.label_tag }} :<br>
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          {{ form.parente }}
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          {{ form.parente.errors }}
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        </td>
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        <td>
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          {{ form.job.label_tag }} :<br>
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          {{ form.job }}
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          {{ form.job.errors }}
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        </td>
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      </tr>
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      <tr>
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        <td>
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          Téléphone personnel :<br>
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          {{ form.mobile }}
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          {{ form.mobile.errors }}
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        </td>
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        <td>
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          Téléphone professionnel :<br>
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          {{ form.phone }}
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          {{ form.phone.errors }}
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        </td>
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        <td>
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          {{ form.email.label_tag }} :<br>
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          {{ form.email }}
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          {{ form.email.errors }}
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        </td>
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      </tr>
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      <tr>
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        <td id="social-security-id">
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          {{ form.social_security_id.label_tag }} :<br>
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          {{ form.social_security_id }}
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          {{ form.social_security_id.errors }}
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          <p id="nir-key">Clé : <span>-</span></p>
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        </td>
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        <td>
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          {{ form.begin_rights.label_tag }} :<br>
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          {{ form.begin_rights }}
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          {{ form.begin_rights.errors }}
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        </td>
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        <td>
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          {{ form.end_rights.label_tag }} :<br>
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          {{ form.end_rights }}
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          {{ form.end_rights.errors }}
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        </td>
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      </tr>
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      <tr>
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        <td>
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          {{ form.health_org.label_tag }} :<br>
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          {{ form.health_org }}
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          {{ form.health_org.errors }}
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        </td>
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        <td>
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          {{ form.other_health_center.label_tag }} :<br>
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          {{ form.other_health_center }}
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          {{ form.other_health_center.errors }}
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        </td>
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        <td>
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          {{ form.type_of_contract.label_tag }} :<br>
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          {{ form.type_of_contract }}
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          {{ form.type_of_contract.errors }}
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        </td>
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      </tr>
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      <tr>
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        <td>
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          {{ form.thirdparty_payer.label_tag }} :<br>
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          {{ form.thirdparty_payer }}
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          {{ form.thirdparty_payer.errors }}
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        </td>
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      </tr>
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      <tr>
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        <td>
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          {{ form.addresses.label_tag }} :
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          {{ form.addresses }}
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          {{ form.addresses.errors }}
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        </td>
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      </tr>
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    </tbody>
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  </table>
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  <p>
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  {{ form.contact_comment.label_tag }}
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  {{ form.contact_comment }}
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  {{ form.contact_comment.errors }}
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  </p>
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 </form>
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