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    <h1>Modifier vos préférences</h1>
    <p>Nous aimerions mieux vous connaître afin de pouvoir vous envoyer des informations qui vous intéressent et qui répondent à vos besoins.</p>
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    <div class="grid__col--4 grid__col--sm12"> jean-philippe-cousin@live.be </div>
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        <input class="e-form__checkbox input-unchecked" type="checkbox" id="newsletter-option-3" name="newsletter-option-3">
        <label class="e-form__label" for="newsletter-option-3">Des lettres d’informations avec des économies sur la consultation du médecin.</label>
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      <label data-select-show="order-warning" data-select-id="15" class="form__label required bold-label">Quels sont les sujets qui vous intéressent ?</label>
      <div>Plusieurs réponses possibles</div>
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Text Content

 * Digne de confiance et sûr
 * Processus de commande facile
 * Livraison discrète
 * Haute appréciation de la clientèle


MODIFIER VOS PRÉFÉRENCES

Nous aimerions mieux vous connaître afin de pouvoir vous envoyer des
informations qui vous intéressent et qui répondent à vos besoins.

Adresse e-mail
jean-philippe-cousin@live.be
Sexe
Homme
Femme
Nom de famille

Date de naissance
jour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
29 30 31
mois janvier février mars avril mai juin juillet août septembre octobre novembre
décembre
année 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914
1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930
1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946
1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962
1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
À quelle fréquence souhaitez-vous recevoir notre lettre d’information ?
2x par semaine 1x par semaine Mensuellement
Quelles lettres d’informations souhaitez-vous recevoir ?
Des lettres d’informations concernant les achats.
Des lettres d’informations concernant la santé.
Des lettres d’informations avec des économies sur la consultation du médecin.
Explication sur les affections et les traitements.
À propos de Dokteronline.com.
Je souhaite me désinscrire de toutes les newsletters.
Quels sont les sujets qui vous intéressent ?
Plusieurs réponses possibles
Perdre du poids
La contraception
La dysfonction érectile
Traitement Hormonal Substitutif
Soulagement de la douleur
MST
Arrêter de fumer
Testostérone (anti-âge)
Autres, notamment...

Enregistrer les préférences