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Formulaire d'inscription CPTS COLMAR AGGLO

The questions marked with an asterisk (*) must be answered.

Civilité

Possible choices

Monsieur

Madame

Open Text Question

Nom - Prénom

Open Text Question

Adresse Mail

Profession

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Médecin

Infirmier

Pharmacien

Diététicien

Biologiste

Autre profession

Open Text Question

RPPS / ADELI

Open Text Question

Lieu d'exercice ( Adresse, Code postal, Ville)

Adhérent CPTS

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Oui, je suis adhérent

Non, mais je m’engage à adhérer à la CPTS Colmar Agglo en cliquant ici

Consentement

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Je consens à ce que cette inscription soit transmise à la CPTS Colmar Agglo

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