{"id":15063,"date":"2024-03-14T14:14:09","date_gmt":"2024-03-14T14:14:09","guid":{"rendered":"https:\/\/www.mutas.be\/?page_id=15063"},"modified":"2025-10-15T13:39:09","modified_gmt":"2025-10-15T11:39:09","slug":"requestformndzv","status":"publish","type":"page","link":"https:\/\/mutas.be\/fr\/requestformndzv\/","title":{"rendered":"Formulaire de demande de transport non-urgent de personnes et de patients"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:4%;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:4%;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div style=\"text-align:center;\"><a class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-1 fusion-button-default-span fusion-button-default-type\" style=\"--button-border-radius-top-left:8px;--button-border-radius-top-right:8px;--button-border-radius-bottom-right:8px;--button-border-radius-bottom-left:8px;--button_margin-bottom:4%;\" target=\"_self\" href=\"#\" data-toggle=\"modal\" data-target=\".fusion-modal.urgent\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Y a-t-il des signes indiquant qu'il s'agit d'une situation mettant la vie en danger ?<\/span><\/a><\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-2 fusion-button-default-span fusion-button-default-type\" style=\"--button-border-radius-top-left:8px;--button-border-radius-top-right:8px;--button-border-radius-bottom-right:8px;--button-border-radius-bottom-left:8px;\" target=\"_self\" href=\"#\" data-toggle=\"modal\" data-target=\".fusion-modal.medical\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Le transport n\u00e9cessite-t-il des proc\u00e9dures m\u00e9dicales ou une surveillance qui ne peuvent \u00eatre effectu\u00e9es que par une infirmi\u00e8re ou un m\u00e9decin, ou s'agit-il d'un transport en dehors du champ d'application de Mutas ?<\/span><\/a><\/div><div class=\"fusion-modal modal fade modal-1 urgentmodal urgent\" tabindex=\"-1\" role=\"dialog\" aria-labelledby=\"modal-heading-1\" aria-hidden=\"true\" style=\"--awb-border-color:#ebebeb;--awb-background:#ffffff;\"><div class=\"modal-dialog modal-lg\" role=\"document\"><div class=\"modal-content fusion-modal-content\"><div class=\"modal-header\"><button class=\"close\" type=\"button\" data-dismiss=\"modal\" aria-hidden=\"true\" aria-label=\"Close\">&times;<\/button><h3 class=\"modal-title\" id=\"modal-heading-1\" data-dismiss=\"modal\" aria-hidden=\"true\">Y a-t-il des signes indiquant qu'il s'agit d'une situation mettant la vie en danger ?<\/h3><\/div><div class=\"modal-body fusion-clearfix\">\n<p>Les situations suivantes peuvent indiquer une situation de danger de mort pour laquelle il est pr\u00e9f\u00e9rable de consulter le 112 :<\/p>\n<ul>\n<li>Perte de conscience\n<ul>\n<li>Absence de r\u00e9ponse, confusion soudaine, perte de conscience : faire le 112<\/li>\n<li>R\u00e9veill\u00e9 et accessible : pas pour le 112<\/li>\n<\/ul>\n<\/li>\n<li>Difficult\u00e9 \u00e0 respirer\n<ul>\n<li>A le souffle court, peut \u00e0 peine parler, ne prononce que des sons : faire le 112<\/li>\n<li>Respire normalement, calmement, fait des phrases compl\u00e8tes : pas pour le 112<\/li>\n<\/ul>\n<\/li>\n<li>L'apparition aigu\u00eb de la douleur\n<ul>\n<li>En cas de respiration, ou dans la r\u00e9gion de la poitrine, ou en cas de blessure (br\u00fblures et coupures) : faire le 112<\/li>\n<\/ul>\n<\/li>\n<li>Chute ou accident avec choc\n<ul>\n<li>Suspicion d'h\u00e9morragie interne : faire le 112<\/li>\n<li>D\u00e9j\u00e0 24 heures \u00e9coul\u00e9es, pas de suspicion d'h\u00e9morragie interne : pas pour le 112<\/li>\n<\/ul>\n<\/li>\n<li>Sensation de malaise\n<ul>\n<li>et il ne s'am\u00e9liore pas en restant \u00e0 plat<br \/>\nen association avec des sueurs, une sensation de moiteur ou des vertiges<br \/>\nen association avec des sensations accrues de naus\u00e9es et\/ou de vomissements : faire le 112<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><div class=\"modal-footer\"><button class=\"fusion-button button-default button-medium button default medium\" type=\"button\" data-dismiss=\"modal\">Close<\/button><\/div><\/div><\/div><\/div><div class=\"fusion-modal modal fade modal-2 medical\" tabindex=\"-1\" role=\"dialog\" aria-labelledby=\"modal-heading-2\" aria-hidden=\"true\" style=\"--awb-border-color:#ebebeb;--awb-background:#ffffff;\"><div class=\"modal-dialog modal-lg\" role=\"document\"><div class=\"modal-content fusion-modal-content\"><div class=\"modal-header\"><button class=\"close\" type=\"button\" data-dismiss=\"modal\" aria-hidden=\"true\" aria-label=\"Close\">&times;<\/button><h3 class=\"modal-title\" id=\"modal-heading-2\" data-dismiss=\"modal\" aria-hidden=\"true\">Le transport n\u00e9cessite-t-il des proc\u00e9dures m\u00e9dicales ou une surveillance qui ne peuvent \u00eatre effectu\u00e9es que par une infirmi\u00e8re ou un m\u00e9decin, ou s'agit-il d'un transport en dehors du champ d'application de Mutas ?<\/h3><\/div><div class=\"modal-body fusion-clearfix\">\n<p>Seules les prestations techniques suivantes peuvent \u00eatre fournies par l'ambulancier qui ne transporte pas de patients en urgence :<\/p>\n<ul>\n<li>lever, soulever et positionner correctement le patient en vue de son transport, y compris le d\u00e9placer avec ou sans aides ;<\/li>\n<li>l'immobilisation pour la s\u00e9curit\u00e9 pendant le transport ;<\/li>\n<li>surveiller la s\u00e9curit\u00e9 physique du patient ;<\/li>\n<li>Surveiller l'\u00e9tat de sant\u00e9 du patient ;<\/li>\n<li>Poursuite du traitement avec de l'oxyg\u00e8ne.<\/li>\n<\/ul>\n<\/div><div class=\"modal-footer\"><button class=\"fusion-button button-default button-medium button default medium\" type=\"button\" data-dismiss=\"modal\">Close<\/button><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f15065-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"15065\">\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\/15063#wpcf7-f15065-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/fr\/wp-json\/wp\/v2\/pages\/15063#wpcf7-f15065-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"15065\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f15065-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<h2>Personne \/ patient \u00e0 transporter\n<\/h2>\n<p><label> Num\u00e9ro de registre national de la personne\/patient \u00e0 transporter<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insz\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"00.00.00-000.00\" value=\"\" type=\"text\" name=\"insz\" \/><\/span><\/label>\n<\/p>\n<p><label> Mutualit\u00e9 de la personne\/patient \u00e0 transporter<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-181\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"menu-181\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"120 - Christelijke mutualiteit\">120 - Christelijke mutualiteit<\/option><option value=\"228 - Mutualia\">228 - Mutualia<\/option><option value=\"203 - Vlaams en Neutraal ziekenfonds\">203 - Vlaams en Neutraal ziekenfonds<\/option><option value=\"235 - Neutraal ziekenfonds Vlaanderen\">235 - Neutraal ziekenfonds Vlaanderen<\/option><option value=\"304 - Solidaris Antwerpen\">304 - Solidaris Antwerpen<\/option><option value=\"306 - Solidaris Brabant\">306 - Solidaris Brabant<\/option><option value=\"309 - Solidaris WVL\">309 - Solidaris WVL<\/option><option value=\"311 - Solidaris OVL\">311 - Solidaris OVL<\/option><option value=\"322 - Solidaris Limburg\">322 - Solidaris Limburg<\/option><option value=\"403 - Mutplus.be\">403 - Mutplus.be<\/option><option value=\"407 - LM OVL\">407 - LM OVL<\/option><option value=\"413 - Mutplus.be\">413 - Mutplus.be<\/option><option value=\"417 - LM Plus\">417 - LM Plus<\/option><option value=\"900 \/ 905 \/ 910 \/ 920 \/ 930 \/ 940 \/ 950 - Sociaal Fonds van HR Rail Fonds Social\">900 \/ 905 \/ 910 \/ 920 \/ 930 \/ 940 \/ 950 - Sociaal Fonds van HR Rail Fonds Social<\/option><\/select><\/span><\/label>\n<\/p>\n<p><label> Nom de la personne\/patient \u00e0 transporter<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><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=\"patient-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Pr\u00e9nom de la personne\/patient \u00e0 transporter<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"patient-firstname\"><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=\"patient-firstname\" \/><\/span> <\/label>\n<\/p>\n<h2>Type de transport demand\u00e9\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-281\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-281\" value=\"Personenwagen - kan zelfstandig stappen\" \/><span class=\"wpcf7-list-item-label\">Voiture normale - peut marcher de mani\u00e8re autonome<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Personenwagen - Heeft hulp nodig (arm, rollator)\" \/><span class=\"wpcf7-list-item-label\">Voiture normale - A besoin d'aide (bras, d\u00e9ambulateur)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Rolstoel - Gewone rolstoel\" \/><span class=\"wpcf7-list-item-label\">Fauteuil roulant - Fauteuil roulant normal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Rolstoel - Grote niet plooibare rolstoel\" \/><span class=\"wpcf7-list-item-label\">Fauteuil roulant - Grand fauteuil roulant non pliant<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Rolstoel - Electrische rolstoel\" \/><span class=\"wpcf7-list-item-label\">Fauteuil roulant - Fauteuil roulant \u00e9lectrique<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Rolstoel - Vervoerder voorziet rolstoel\" \/><span class=\"wpcf7-list-item-label\">Fauteuil roulant - Le transporteur fournit le fauteuil roulant<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Rolstoel - Persoon neemt veilig verankerbare scooter mee\" \/><span class=\"wpcf7-list-item-label\">Fauteuil roulant - La personne prend un scooter solidement ancr\u00e9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Ambulance - Verwardheid \/ desori\u00ebntatie \/ ... en er gaat GEEN begeleider mee\" \/><span class=\"wpcf7-list-item-label\">Ambulance - Confusion \/ d\u00e9sorientation \/ ... et il n'y a PAS d'accompagnateur<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Ambulance - Risico op agressie en er gaat GEEN begeleider mee\" \/><span class=\"wpcf7-list-item-label\">Ambulance - Risque d'agression et il n'y a PAS de personne accompagnante<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Ambulance - Noodzaak tot decontaminatie\" \/><span class=\"wpcf7-list-item-label\">Ambulance - N\u00e9cessit\u00e9 d'une d\u00e9contamination<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Ambulance - Toediening zuurstof\" \/><span class=\"wpcf7-list-item-label\">Ambulance - Administration d'oxyg\u00e8ne<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-281\" value=\"Ambulance - Pati\u00ebnt dient met draagstoel verplaatst te worden\" \/><span class=\"wpcf7-list-item-label\">Ambulance - Le patient doit \u00eatre d\u00e9plac\u00e9 sur une civi\u00e8re<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-281\" value=\"Ambulance - Pati\u00ebnt dient in liggende positie vervoerd\" \/><span class=\"wpcf7-list-item-label\">Ambulance - Le patient doit \u00eatre transport\u00e9 en position allong\u00e9e<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p>Veuillez indiquer le type de transport d\u00e9sir\u00e9\n<\/p>\n<h2>Sp\u00e9cifications\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-carry\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-carry[]\" value=\"De vervoersdienst moet de pati\u00ebnt op ophaaladres of bestemming een trap op dragen\" \/><span class=\"wpcf7-list-item-label\">Le service de transport doit porter le patient pour monter les escaliers \u00e0 l'adresse de prise en charge ou \u00e0 la destination.<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label>De porte \u00e0 porte<\/label><br \/>\n<label>La personne peut-elle se d\u00e9placer seule du v\u00e9hicule jusqu'\u00e0 l'entr\u00e9e de la destination ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-dtd\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-dtd[]\" value=\"De pati\u00ebnt kan zich zelfstandig verplaatsen\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Le patient peut se d\u00e9placer de mani\u00e8re autonome.<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label>Autonomie<\/label><br \/>\n<label>La personne est-elle accompagn\u00e9e ou est-elle suffisamment autonome pour se d\u00e9placer et s'inscrire \u00e0 l'h\u00f4pital sans l'aide du transporteur ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-zelfR\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"checkbox-zelfR[]\" value=\"De pati\u00ebnt is zelfredzaam\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Le patient est autonome<\/span><\/span><\/span><\/span>\n<\/p>\n<p><label>Risque d'infection<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-infection\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-infection\" value=\"Geen infectierisico\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Aucun risque d'infection<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-infection\" value=\"Druppelrisico waarbij mondneusmasker nodig is\" \/><span class=\"wpcf7-list-item-label\">Risque de gouttelettes n\u00e9cessitant un masque buccal et nasal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-infection\" value=\"Aerogeen risico waarbij FFP2 nodig is\" \/><span class=\"wpcf7-list-item-label\">Risque a\u00e9rog\u00e8ne n\u00e9cessitant un FFP2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-infection\" value=\"Contactrisico waarbij handschoenen nodig zijn\" \/><span class=\"wpcf7-list-item-label\">Risque de contact n\u00e9cessitant des gants<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-infection\" value=\"Contactrisico waarbij handschoenen en schort nodig zijn\" \/><span class=\"wpcf7-list-item-label\">Risque de contact n\u00e9cessitant des gants et une robe<\/span><\/label><\/span><\/span><\/span><br \/>\n<label>Oxyg\u00e8ne<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-zuurstof\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-zuurstof\" value=\"Geen zuurstof nodig\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Pas d'oxyg\u00e8ne n\u00e9cessaire<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-zuurstof\" value=\"0 - 2 L\" \/><span class=\"wpcf7-list-item-label\">0 - 2 L<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-zuurstof\" value=\"2 - 6 L\" \/><span class=\"wpcf7-list-item-label\">2 - 6 L<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<h2>Accompagnement\n<\/h2>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"begeleiding\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"begeleiding\" value=\"Geen bijkomende passagiers\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Aucun passager suppl\u00e9mentaire<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"begeleiding\" value=\"1 extra niet-zorgbehoevende passagier\" \/><span class=\"wpcf7-list-item-label\">1 passager non d\u00e9pendant additionnel<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<h2>Transport\n<\/h2>\n<p><label><b>D\u00e9part<\/b><\/label><br \/>\n<label>Adresse du domicile ou Nom de l'institution + campus (si applicable)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"depInst\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"depInst\" \/><\/span><\/label><br \/>\n<label> Adresse<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Vertrekadres\"><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=\"Vertrekadres\" \/><\/span><\/label>\n<\/p>\n<p><label><b>Destination<\/b><\/label><br \/>\n<label>Adresse du domicile ou Nom de l'institution + campus (si applicable)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"desInst\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"desInst\" \/><\/span><\/label><br \/>\n<label> Adresse<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Bestemming\"><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=\"Bestemming\" \/><\/span><\/label>\n<\/p>\n<p><label> Raison du transport<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reden\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"reden\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Consultatie \/ Onderzoek \/ Behandeling in een ziekenhuis - Consultation \/ Examen \/ Traitement dans un h\u00f4pital\">Consultatie \/ Onderzoek \/ Behandeling in een ziekenhuis - Consultation \/ Examen \/ Traitement dans un h\u00f4pital<\/option><option value=\"Consultatie in gipskamer - Consultation en salle de pl\u00e2tre\">Consultatie in gipskamer - Consultation en salle de pl\u00e2tre<\/option><option value=\"Consultatie praktijk (arts \/ tandarts) - Cabinet de consultation (m\u00e9decin \/ dentiste)\">Consultatie praktijk (arts \/ tandarts) - Cabinet de consultation (m\u00e9decin \/ dentiste)<\/option><option value=\"Dagopname - Hospitalisation de jour\">Dagopname - Hospitalisation de jour<\/option><option value=\"Dialyse\">Dialyse<\/option><option value=\"Interhospitaalvervoer op eigen vraag en eigen kosten van de pati\u00ebnt - Transport interhospitalier \u00e0 la demande et aux frais du patient\">Interhospitaalvervoer op eigen vraag en eigen kosten van de pati\u00ebnt - Transport interhospitalier \u00e0 la demande et aux frais du patient<\/option><option value=\"Kortverblijf in een woonzorgcentrum - Court s\u00e9jour dans une maison de repos\">Kortverblijf in een woonzorgcentrum - Court s\u00e9jour dans une maison de repos<\/option><option value=\"Nachtdialyse - Dialyse pendant le nuit\">Nachtdialyse - Dialyse pendant le nuit<\/option><option value=\"Niertransplantatie &amp; Nabehandeling - Transplantation r\u00e9nale &amp; Traitement post-greffe\">Niertransplantatie &amp; Nabehandeling - Transplantation r\u00e9nale &amp; Traitement post-greffe<\/option><option value=\"Oncologische behandeling - Traitement oncologique\">Oncologische behandeling - Traitement oncologique<\/option><option value=\"Oncologische follow-up (Enkel na een behandeling) - Suivi oncologique (Uniquement apr\u00e8s un traitement)\">Oncologische follow-up (Enkel na een behandeling) - Suivi oncologique (Uniquement apr\u00e8s un traitement)<\/option><option value=\"Opname of ontslag in een herstelverblijf - Centre de convalescence (Entr\u00e9e ou sortie)\">Opname of ontslag in een herstelverblijf - Centre de convalescence (Entr\u00e9e ou sortie)<\/option><option value=\"Opname of ontslag in een woon\/zorg-centrum - S\u00e9jour d\u00e9finitif un maison de repos\">Opname of ontslag in een woon\/zorg-centrum - S\u00e9jour d\u00e9finitif un maison de repos<\/option><option value=\"Orgaantransplantatie &amp; Nabehandelingen - Transplantation d&#039;organes &amp; Post-traitement\">Orgaantransplantatie &amp; Nabehandelingen - Transplantation d&#039;organes &amp; Post-traitement<\/option><option value=\"Pediatrische dialyse - Dialyse p\u00e9diatrique\">Pediatrische dialyse - Dialyse p\u00e9diatrique<\/option><option value=\"Radiotherapie &amp; follow-up consultaties - Radioth\u00e9rapie &amp; consultations de suivi\">Radiotherapie &amp; follow-up consultaties - Radioth\u00e9rapie &amp; consultations de suivi<\/option><option value=\"Revalidatie (niet cardiaal) - R\u00e9validation (non-cardiaque)\">Revalidatie (niet cardiaal) - R\u00e9validation (non-cardiaque)<\/option><option value=\"Terugrit na ambulante zorg - Retour apr\u00e8s soins ambulatoires\">Terugrit na ambulante zorg - Retour apr\u00e8s soins ambulatoires<\/option><option value=\"Vakantiedialyse - Dialyse pendant les vacances\">Vakantiedialyse - Dialyse pendant les vacances<\/option><option value=\"Verblijfsonderbreking - Interruption de s\u00e9jour (d&#039;un hopital)\">Verblijfsonderbreking - Interruption de s\u00e9jour (d&#039;un hopital)<\/option><option value=\"Ziekenhuisontslag - Sorti d&#039; h\u00f4pital\">Ziekenhuisontslag - Sorti d&#039; h\u00f4pital<\/option><option value=\"Ziekenhuisopname - Hospitalisation\">Ziekenhuisopname - Hospitalisation<\/option><\/select><\/span><\/label>\n<\/p>\n<div class=\"form-element\"  style=\"max-width:340px;\">\n\t<p><label> Date du transport<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Datum\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" min=\"2026-04-05\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"Datum\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"form-element\"  style=\"max-width:340px;\">\n\t<p><label> Heure du rendez-vous\/ heure de la sortie d\u2019hopital<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Tijdstip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required walcf7-timepicker\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Tijdstip\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Terugrit\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"Terugrit[]\" value=\"Mutas dient de terugrit te verzorgen\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Mutas devrait prendre en charge le voyage de retour<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<div class=\"form-element\"  style=\"max-width:340px;\">\n\t<p><label> Heure du retour (si elle est connue)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Tijdstip-Terugrit\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text walcf7-timepicker\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Tijdstip-Terugrit\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<p><label> Transport en s\u00e9rie (si applicable)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"reeks\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Inscrivez ici toutes les dates et heures en cas de transport en s\u00e9rie ou joignez-les ci-dessous.\" name=\"reeks\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label>Annexe<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-upload\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"image\/*,.txt,application\/pdf\" aria-invalid=\"false\" type=\"file\" name=\"file-upload\" \/><\/span>\n<\/p>\n<h2>Facturation\n<\/h2>\n<p><label> Email pour la facturation<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"invoiceMail\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"invoiceMail\" \/><\/span> <\/label><br \/>\nOu<br \/>\n<label> Adresse de facturation<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"invoiceAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"invoiceAddress\" \/><\/span> <\/label>\n<\/p>\n<h2>Confirmation\n<\/h2>\n<p><label> Votre nom<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" autocomplete=\"name\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Votre e-mail<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n<\/p>\n<p><label>Confirmez votre e-mail<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email-conf\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" autocomplete=\"email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email-conf\" \/><\/span> <\/label>\n<\/p>\n<p><label> Votre num\u00e9ro de t\u00e9l\u00e9phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phone\" \/><\/span> <\/label>\n<\/p>\n<h2>Informations suppl\u00e9mentaires\n<\/h2>\n<p><label> Transporteur pr\u00e9f\u00e9r\u00e9<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"preferredTransporter\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Nom du transporteur\" value=\"\" type=\"text\" name=\"preferredTransporter\" \/><\/span> <\/label>\n<\/p>\n<p><label> \u00c9vitez le transporteur<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"avoidTransporter\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Nom du transporteur\" value=\"\" type=\"text\" name=\"avoidTransporter\" \/><\/span> <\/label>\n<\/p>\n<p><label> Remarques (optionnel)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-message\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"Sp\u00e9cifications qui peuvent \u00eatre importantes pour l&#039;organisation du transport, par exemple les sp\u00e9cifications m\u00e9dicales, le poids du patient, la r\u00e9sidence \u00e0 l&#039;\u00e9tage avec\/sans ascenseur, ...\" name=\"your-message\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"accept\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"accept\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">En cochant cette case, vous confirmez que vous acceptez notre <a href=\"https:\/\/www.mutas.be\/nl\/privacy-policy\/\">privacy policy<\/a> et la conservation des donn\u00e9es enregistr\u00e9es de ce formulaire<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer*\" \/>\n<\/p>\n<p>*En soumettant ce formulaire, je d\u00e9clare que toutes les donn\u00e9es saisies sont correctes et que je suis conscient et accepte que Mutas organise le transport demand\u00e9 dans ce formulaire conform\u00e9ment aux statuts de la mutuelle de la personne\/patient \u00e0 transporter, dont je d\u00e9clare \u00eatre conscient.\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"236\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output fusion-alert-capitalize awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-size:1px;--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form>\n<\/div>\n<div class=\"fusion-text fusion-text-1\"><p style=\"text-align: right;\">Cette page utilise reCAPTCHA lors de la soumission de ce formulaire.<\/p>\n<\/div><\/div><\/div><\/div><\/div><\/p>","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-15063","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/pages\/15063","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/comments?post=15063"}],"version-history":[{"count":18,"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/pages\/15063\/revisions"}],"predecessor-version":[{"id":15102,"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/pages\/15063\/revisions\/15102"}],"wp:attachment":[{"href":"https:\/\/mutas.be\/fr\/wp-json\/wp\/v2\/media?parent=15063"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}