{"id":3635,"date":"2020-12-15T01:14:12","date_gmt":"2020-12-15T06:14:12","guid":{"rendered":"https:\/\/www.merbleuedental.com\/?page_id=3635"},"modified":"2023-06-22T05:20:58","modified_gmt":"2023-06-22T09:20:58","slug":"formulaire-de-consentement-du-patient","status":"publish","type":"page","link":"https:\/\/www.merbleuedental.com\/fr\/formulaire-de-consentement-du-patient\/","title":{"rendered":"Formulaire de consentement du patient"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; fullwidth=\u00a0\u00bbon\u00a0\u00bb _builder_version=\u00a0\u00bb4.16&Prime; background_enable_image=\u00a0\u00bboff\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_fullwidth_header title=\u00a0\u00bbFORMULAIRE DE CONSENTEMENT DU PATIENT\u00a0\u00bb header_fullscreen=\u00a0\u00bbon\u00a0\u00bb _builder_version=\u00a0\u00bb4.18.0&Prime; title_font=\u00a0\u00bb|700|||||||\u00a0\u00bb title_text_color=\u00a0\u00bb#000000&Prime; 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class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/fr\/wp-json\/wp\/v2\/pages\/3635#gf_8' data-formid='8' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeCWBUiAAAAANv34xcxvYKHX6-NK2IdU12ogpU2' data-tabindex='0'><input id=\"input_3f1b158930940546112d3662d483e257\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_3f1b158930940546112d3662d483e257\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_4\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_4'>Type de patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_8_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Adulte' >Adulte<\/option><option value='Enfant' >Enfant<\/option><option value='Adulte sous tutelle' >Adulte sous tutelle<\/option><\/select><\/div><\/div><fieldset id=\"field_8_5\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du tuteur<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_5'>\n                            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gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_6'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_8_6' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_8_7\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du patient<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_7'>\n                            \n                            <span id='input_8_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_8_7_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_8_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_8_7_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_8_7_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_8\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_8'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_8_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_8_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_8_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_8' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_9\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_9'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_8_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_12\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>En signant ceci, vous reconnaissez avoir donn\u00e9 votre consentement \u00e9clair\u00e9 \u00e0 la collecte, \u00e0 l'utilisation et\/ou \u00e0 la divulgation de vos informations personnelles aux fins \u00e9num\u00e9r\u00e9es. Si une nouvelle finalit\u00e9 se pr\u00e9sente pour l'utilisation et\/ou la divulgation de vos informations personnelles, nous vous demanderons votre accord au pr\u00e9alable. Les autorit\u00e9s r\u00e9glementaires peuvent avoir acc\u00e8s \u00e0 vos informations en vertu de la Loi sur les professions de sant\u00e9 r\u00e9glement\u00e9es (RHPA) afin que le Coll\u00e8ge Royale des Chirurgiens Dentistes de l'Ontario puisse remplir son mandat en vertu de la (RHPA), et pour la d\u00e9fense d'une question juridique. Notre bureau ne fournira jamais \u00e0 votre assurance vos ant\u00e9c\u00e9dents m\u00e9dicaux confidentiels. En cas de demande de ce type, nous vous envoyons directement les informations pour votre r\u00e9vision et pour obtenir votre consentement sp\u00e9cifique. Lorsque nous recevons des demandes inhabituelles, nous vous contactons pour vous demander l'autorisation de divulguer les informations n\u00e9cessaires. Nous pouvons \u00e9galement vous informer si une telle divulgation n'est pas appropri\u00e9e. Lorsque vous retirez votre consentement \u00e0 l'utilisation ou \u00e0 la divulgation de vos informations personnelles, nous vous expliquons les cons\u00e9quences de cette d\u00e9cision et la proc\u00e9dure \u00e0 suivre.<\/p><\/div><div id=\"field_8_10\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_10'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_10' id='input_8_10_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_8_10_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_8_10' width='300' height='180' style='border-style: Dashed; border-width: 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jQuery(document).scrollTop(jQuery('#gform_wrapper_8').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_8').val();gformInitSpinner( 8, 'https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [8, current_page]);window['gf_submitting_8'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_8').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_8').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [8]);window['gf_submitting_8'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_8').text());}else{jQuery('#gform_8').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"8\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_8\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_8\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_8\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 8, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && 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informations personnelles\u00a0\u00bb open=\u00a0\u00bbon\u00a0\u00bb _builder_version=\u00a0\u00bb4.18.0&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb custom_margin=\u00a0\u00bb||10px||false|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||true|false\u00a0\u00bb border_radii=\u00a0\u00bbon|20px|20px|20px|20px\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb toggle_level=\u00a0\u00bbh4&Prime;]<\/p>\n<h5>(pour la collecte, l&rsquo;utilisation et la divulgation de renseignements personnels)<\/h5>\n<p>La confidentialit\u00e9 de vos informations personnelles est une partie importante de notre cabinet, tout comme vous fournir des soins dentaires de qualit\u00e9. Nous comprenons l&rsquo;importance de prot\u00e9ger vos informations personnelles et nous nous engageons \u00e0 collecter, utiliser et divulguer vos informations personnelles de mani\u00e8re responsable. Nous essayons \u00e9galement d&rsquo;\u00eatre aussi ouverts et transparents que possible sur la fa\u00e7on dont nous traitons vos informations personnelles. Il est tr\u00e8s important pour nous de fournir ce service \u00e0 tous nos patients.<\/p>\n<p>Dans ce cabinet dentaire, le directeur du bureau agit en tant que responsable de la confidentialit\u00e9. Tous les membres du personnel qui entrent en contact avec vos informations personnelles sont conscients de la nature sensible des informations que vous nous avez divulgu\u00e9es. Ils sont tous form\u00e9s aux utilisations appropri\u00e9es et \u00e0 la protection de vos informations. Voici une politique d\u00e9crite que notre bureau suit pour vous assurer que :<\/p>\n<ul>\n<li>Seules les informations n\u00e9cessaires sont collect\u00e9es aupr\u00e8s de vous.<\/li>\n<li>Nous ne partageons vos informations qu&rsquo;avec votre consentement.<\/li>\n<li>Le stockage, la conservation et la destruction appropri\u00e9e de vos informations personnelles sont conformes \u00e0 la l\u00e9gislation en vigueur et aux protocoles de protection de la vie priv\u00e9e.<\/li>\n<li>Nos protocoles de confidentialit\u00e9 sont conformes \u00e0 la l\u00e9gislation sur la confidentialit\u00e9, aux normes de notre organisme de r\u00e9glementation, le Coll\u00e8ge royal des chirurgiens dentistes de l&rsquo;Ontario, et \u00e0 la loi.<\/li>\n<\/ul>\n<p>N&rsquo;h\u00e9sitez pas \u00e0 discuter de nos politiques avec n&rsquo;importe quel membre de notre personnel de bureau.<\/p>\n<p>Soyez assur\u00e9 que chaque membre du personnel de notre cabinet s&rsquo;engage \u00e0 veiller \u00e0 ce que vous receviez des soins dentaires de la meilleure qualit\u00e9.<\/p>\n<p>[\/et_pb_accordion_item][et_pb_accordion_item title=\u00a0\u00bbComment notre bureau recueille, utilise et divulgue les renseignements personnels des patients\u00a0\u00bb _builder_version=\u00a0\u00bb4.18.0&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb custom_margin=\u00a0\u00bb||10px||false|false\u00a0\u00bb custom_padding=\u00a0\u00bb0px||0px||true|false\u00a0\u00bb border_radii=\u00a0\u00bbon|20px|20px|20px|20px\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb toggle_level=\u00a0\u00bbh4&Prime; open=\u00a0\u00bboff\u00a0\u00bb]<\/p>\n<p>Comment notre bureau recueille, utilise et divulgue les renseignements personnels des patients Pour vous aider \u00e0 comprendre comment nous proc\u00e9dons, nous avons d\u00e9crit ici comment notre bureau utilise et divulgue vos informations. Notre bureau recueillera, utilisera et divulguera des renseignements vous concernant aux fins suivantes pour :<\/p>\n<ul>\n<li>offrir des soins s\u00e9curitaires et efficaces aux patients.<\/li>\n<li>identifier et assurer un service continu de qualit\u00e9.<\/li>\n<li>acc\u00e9der \u00e0 vos besoins de sant\u00e9.<\/li>\n<li>vous conseiller sur les options de traitement.<\/li>\n<li>\u00e9tablir et maintenir la communication avec vous.<\/li>\n<li>nous permettre de vous contacter.<\/li>\n<li>offrir et fournir des traitements, des soins et des services li\u00e9s aux soins bucco-dentaires.<\/li>\n<li>communiquer avec d&rsquo;autres fournisseurs de soins de sant\u00e9 traitants, y compris des sp\u00e9cialistes et des dentistes g\u00e9n\u00e9ralistes qui sont des dentistes r\u00e9f\u00e9rents et\/ou des dentistes p\u00e9riph\u00e9riques.<\/li>\n<li>nous permettre de maintenir la communication et le contact avec vous pour diffuser des informations sur les soins de sant\u00e9 et pour r\u00e9server et confirmer des rendez-vous.<\/li>\n<li>nous permettent de suivre efficacement le traitement, les soins et la facturation<\/li>\n<li>\u00e0 des fins d&rsquo;enseignement et de d\u00e9monstration sur une base anonyme.<\/li>\n<li>remplir et soumettre les r\u00e9clamations dentaires et les estimations pour l&rsquo;arbitrage et le paiement par un tiers.<\/li>\n<li>se conformer aux exigences l\u00e9gales et r\u00e9glementaires, y compris la livraison des dossiers et des dossiers des patients au Coll\u00e8ge royal des chirurgiens dentistes de l&rsquo;Ontario en temps opportun, au besoin, conform\u00e9ment aux dispositions de la Loi sur les professions de la sant\u00e9 r\u00e9glement\u00e9es.<\/li>\n<li>se conformer aux accords\/engagements conclus volontairement par le membre avec les dossiers et dossiers des patients \u00e0 l&rsquo;Ordre en temps opportun \u00e0 des fins de r\u00e9glementation et de surveillance.<\/li>\n<li>pr\u00e9parer des documents pour la Commission d&rsquo;appel et de r\u00e9vision des professions de la sant\u00e9 (HPARB). facture des biens et services.<\/li>\n<li>traiter les paiements par carte de cr\u00e9dit.<\/li>\n<li>recouvrer les comptes impay\u00e9s.<\/li>\n<li>aider ce bureau \u00e0 se conformer \u00e0 toutes les exigences r\u00e9glementaires.<\/li>\n<li>respecter g\u00e9n\u00e9ralement la loi.<\/li>\n<\/ul>\n<p>[\/et_pb_accordion_item][\/et_pb_accordion][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_8' style='display:none'><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/fr\/wp-json\/wp\/v2\/pages\/3635#gf_8' data-formid='8' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeCWBUiAAAAANv34xcxvYKHX6-NK2IdU12ogpU2' data-tabindex='0'><input id=\"input_3f1b158930940546112d3662d483e257\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_3f1b158930940546112d3662d483e257\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_4\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_4'>Type de patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_8_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Adulte' >Adulte<\/option><option value='Enfant' >Enfant<\/option><option value='Adulte sous tutelle' >Adulte sous tutelle<\/option><\/select><\/div><\/div><fieldset id=\"field_8_5\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du tuteur<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_5'>\n                            \n                            <span id='input_8_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_8_5_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_8_5_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_8_5_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_8_5_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_6'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_8_6' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_8_7\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du patient<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_7'>\n                            \n                            <span id='input_8_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_8_7_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_8_7_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_8_7_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_8_7_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_8_8\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_8'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_8_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_8_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_8_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_8' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_8_9\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_9'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_8_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_12\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>En signant ceci, vous reconnaissez avoir donn\u00e9 votre consentement \u00e9clair\u00e9 \u00e0 la collecte, \u00e0 l'utilisation et\/ou \u00e0 la divulgation de vos informations personnelles aux fins \u00e9num\u00e9r\u00e9es. Si une nouvelle finalit\u00e9 se pr\u00e9sente pour l'utilisation et\/ou la divulgation de vos informations personnelles, nous vous demanderons votre accord au pr\u00e9alable. Les autorit\u00e9s r\u00e9glementaires peuvent avoir acc\u00e8s \u00e0 vos informations en vertu de la Loi sur les professions de sant\u00e9 r\u00e9glement\u00e9es (RHPA) afin que le Coll\u00e8ge Royale des Chirurgiens Dentistes de l'Ontario puisse remplir son mandat en vertu de la (RHPA), et pour la d\u00e9fense d'une question juridique. Notre bureau ne fournira jamais \u00e0 votre assurance vos ant\u00e9c\u00e9dents m\u00e9dicaux confidentiels. En cas de demande de ce type, nous vous envoyons directement les informations pour votre r\u00e9vision et pour obtenir votre consentement sp\u00e9cifique. Lorsque nous recevons des demandes inhabituelles, nous vous contactons pour vous demander l'autorisation de divulguer les informations n\u00e9cessaires. Nous pouvons \u00e9galement vous informer si une telle divulgation n'est pas appropri\u00e9e. Lorsque vous retirez votre consentement \u00e0 l'utilisation ou \u00e0 la divulgation de vos informations personnelles, nous vous expliquons les cons\u00e9quences de cette d\u00e9cision et la proc\u00e9dure \u00e0 suivre.<\/p><\/div><div id=\"field_8_10\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_10'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_10' id='input_8_10_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_8_10_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_8_10' width='300' height='180' style='border-style: Dashed; border-width: 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