{"id":5184,"date":"2022-08-29T03:43:07","date_gmt":"2022-08-29T07:43:07","guid":{"rendered":"https:\/\/www.merbleuedental.com\/formulaire-dantecedents-medicaux-du-nouveau-patient\/"},"modified":"2024-02-19T03:55:43","modified_gmt":"2024-02-19T08:55:43","slug":"formulaire-dantecedents-medicaux-du-nouveau-patient","status":"publish","type":"page","link":"https:\/\/www.merbleuedental.com\/fr\/formulaire-dantecedents-medicaux-du-nouveau-patient\/","title":{"rendered":"Formulaire d\u2019ant\u00e9c\u00e9dents m\u00e9dicaux du nouveau 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\u00bbCentre Dentaire Mer Bleue\u00a0\u00bb subhead=\u00a0\u00bbL&apos;exp\u00e9rience dentaire d&apos;Orl\u00e9ans\u00a0\u00bb header_fullscreen=\u00a0\u00bbon\u00a0\u00bb button_one_text=\u00a0\u00bbDemander un rendez-vous\u00a0\u00bb button_one_url=\u00a0\u00bb@ET-DC@eyJkeW5hbWljIjp0cnVlLCJjb250ZW50IjoicG9zdF9saW5rX3VybF9wYWdlIiwic2V0dGluZ3MiOnsicG9zdF9pZCI6IjI4In19@\u00a0\u00bb _builder_version=\u00a0\u00bb4.16&Prime; _dynamic_attributes=\u00a0\u00bbbutton_one_url\u00a0\u00bb title_font=\u00a0\u00bb|700|||||||\u00a0\u00bb title_text_color=\u00a0\u00bb#000000&Prime; title_font_size=\u00a0\u00bb39px\u00a0\u00bb subhead_text_color=\u00a0\u00bb#000000&Prime; subhead_font_size=\u00a0\u00bb24px\u00a0\u00bb subhead_line_height=\u00a0\u00bb2.3em\u00a0\u00bb background_image=\u00a0\u00bbhttps:\/\/www.merbleuedental.com\/wp-content\/uploads\/2021\/04\/forms-banner.png\u00a0\u00bb background_position=\u00a0\u00bbcenter_right\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=\u00a0\u00bb1&Prime; _builder_version=\u00a0\u00bb4.16&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_row _builder_version=\u00a0\u00bb4.16&Prime; background_size=\u00a0\u00bbinitial\u00a0\u00bb background_position=\u00a0\u00bbtop_left\u00a0\u00bb background_repeat=\u00a0\u00bbrepeat\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb4.16&Prime; custom_padding=\u00a0\u00bb|||\u00a0\u00bb global_colors_info=\u00a0\u00bb{}\u00a0\u00bb custom_padding__hover=\u00a0\u00bb|||\u00a0\u00bb][et_pb_text _builder_version=\u00a0\u00bb4.18.0&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb hover_enabled=\u00a0\u00bb0&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb sticky_enabled=\u00a0\u00bb0&Prime;]<\/p>\n<h1 class=\"et_pb_module_header\">Formulaire d\u2019ant\u00e9c\u00e9dents m\u00e9dicaux du nouveau patient<\/h1>\n<p>[\/et_pb_text][et_pb_code _builder_version=\u00a0\u00bb4.18.0&Prime; global_colors_info=\u00a0\u00bb{}\u00a0\u00bb]<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\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_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">NOUVEAU FORMULAIRE PATIENT<\/h2>\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_4' id='gform_4'  action='\/fr\/wp-json\/wp\/v2\/pages\/5184#gf_4' data-formid='4' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeCWBUiAAAAANv34xcxvYKHX6-NK2IdU12ogpU2' data-tabindex='0'><input id=\"input_1c9cb9763a57953039690a5d3630d98b\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_1c9cb9763a57953039690a5d3630d98b\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_97\" class=\"gfield gfield--type-select gfield--width-full 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_4_97'>Comment avez-vous entendu parler de notre clinique dentaire?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_4_97' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >S\u00e9lectionner<\/option><option value='Renvoi de patient' >Renvoi de patient<\/option><option value='R\u00e9side dans la r\u00e9gion' >R\u00e9side dans la r\u00e9gion<\/option><option value='Travaille \u00e0 proximit\u00e9' >Travaille \u00e0 proximit\u00e9<\/option><option value='Radio' >Radio<\/option><option value='M\u00e9diaux sociaux' >M\u00e9diaux sociaux<\/option><option value='Autres' >Autre<\/option><\/select><\/div><\/div><div id=\"field_4_99\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_99'>Donnez quelques d\u00e9tails :<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_99' id='input_4_99' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_3\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2> Coordonn\u00e9es des patients <\/h2><\/div><div id=\"field_4_81\" class=\"gfield gfield--type-select gfield--width-full 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_4_81'>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_81' id='input_4_81' 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_4_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_4_5'>\n                            \n                            <span id='input_4_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_4_5_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_4_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_4_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_4_5_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_4_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><fieldset id=\"field_4_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Genre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_6'>\n\t\t\t<div class='gchoice gchoice_4_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='M\u00e2le'  id='choice_4_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_0' id='label_4_6_0' class='gform-field-label gform-field-label--type-inline'>M\u00e2le<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Femme'  id='choice_4_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_1' id='label_4_6_1' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Autre'  id='choice_4_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_2' id='label_4_6_2' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_101\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_101'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_4_101' type='text' value='' class='large'    placeholder='Donnez quelques d\u00e9tails'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_7\" class=\"gfield gfield--type-name gfield_contains_required 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<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/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_4_7'>\n                            \n                            <span id='input_4_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_4_7_3' value=''   aria-required='true'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_4_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_4_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_4_7_6' value=''   aria-required='true'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_4_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_4_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_4_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_4_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_8_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_8' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_9\" class=\"gfield gfield--type-address gfield_contains_required 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' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_4_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_4_9_1' value=''   placeholder='Adresse 1' aria-required='true'    \/>\n                                        <label for='input_4_9_1' id='input_4_9_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Adresse postale<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_9.4' id='input_4_9_4' value=''\/><input type='hidden' class='gform_hidden' name='input_9.6' id='input_4_9_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_4_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_12'>Ville<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='large'    placeholder='Ville' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_10\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_10'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_4_10' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='S\u00e9lectionnez la province' >S\u00e9lectionnez la province<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie britannique' >Colombie britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du nord-ouest' >Territoires du nord-ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select><\/div><\/div><div id=\"field_4_13\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'>Code Postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_4_13' type='text' value='' class='large'    placeholder='Code Postal' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_14\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Pays<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_4_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Choisissez le pays' >Choisissez le pays<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Iles Aland' >Iles Aland<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='L&#039;Autriche' >L&#039;Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bengladesh' >Bengladesh<\/option><option value='Barbade' >Barbade<\/option><option value='Bi\u00e9lorussie' >Bi\u00e9lorussie<\/option><option value='Belgique' >Belgique<\/option><option value='B\u00e9lize' >B\u00e9lize<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bosnie Herz\u00e9govine' >Bosnie Herz\u00e9govine<\/option><option value='Bostwana' >Bostwana<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Territoire britannique de l&#039;oc\u00e9an Indien' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='\u00celes Ca\u00efmans' >\u00celes Ca\u00efmans<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='Tchad' >Tchad<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='L&#039;\u00eele de no\u00ebl' >L&#039;\u00eele de no\u00ebl<\/option><option value='\u00celes Cocos (Keeling)' >\u00celes Cocos (Keeling)<\/option><option value='Colombie&quot; &quot;Comores' >Colombie&quot; &quot;Comores<\/option><option value='Congo' >Congo<\/option><option value='Congo, R\u00e9publique D\u00e9mocratique du' >Congo, R\u00e9publique D\u00e9mocratique du<\/option><option value='les \u00celes Cook' >les \u00celes Cook<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te D&#039;ivoire' >C\u00f4te D&#039;ivoire<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Chypre' >Chypre<\/option><option value='R\u00e9publique tch\u00e8que' >R\u00e9publique tch\u00e8que<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='R\u00e9publique dominicaine' >R\u00e9publique dominicaine<\/option><option value='Equateur' >Equateur<\/option><option value='Egypte' >Egypte<\/option><option value='Le Salvador' >Le Salvador<\/option><option value='Guin\u00e9e \u00c9quatoriale' >Guin\u00e9e \u00c9quatoriale<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='Estonie' >Estonie<\/option><option value='Ethiopie' >Ethiopie<\/option><option value='\u00celes Falkland (Malouines)' >\u00celes Falkland (Malouines)<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Guyane Fran\u00e7aise' >Guyane Fran\u00e7aise<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Terres australes fran\u00e7aises' >Terres australes fran\u00e7aises<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Groenland' >Groenland<\/option><option value='Grenade' >Grenade<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernesey' >Guernesey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e-bissau' >Guin\u00e9e-bissau<\/option><option value='Guyane' >Guyane<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='\u00cele Heard et \u00celes Mcdonald' >\u00cele Heard et \u00celes Mcdonald<\/option><option value='Saint-Si\u00e8ge (\u00c9tat de la Cit\u00e9 du Vatican)' >Saint-Si\u00e8ge (\u00c9tat de la Cit\u00e9 du Vatican)<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Islande' >Islande<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Iran (R\u00e9publique islamique d' >Iran (R\u00e9publique islamique d<\/option><option value='Irak' >Irak<\/option><option value='Irlande' >Irlande<\/option><option value='\u00eele de Man' >\u00eele de Man<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='R\u00e9publique populaire d\u00e9mocratique de Cor\u00e9e' >R\u00e9publique populaire d\u00e9mocratique de Cor\u00e9e<\/option><option value='Cor\u00e9e, R\u00e9publique de' >Cor\u00e9e, R\u00e9publique de<\/option><option value='Koweit' >Koweit<\/option><option value='Kirghizistan' >Kirghizistan<\/option><option value='R\u00e9publique d\u00e9mocratique populaire lao' >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lib\u00e9ria' >Lib\u00e9ria<\/option><option value='Jamahiriya arabe libyenne' >Jamahiriya arabe libyenne<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Mac\u00e9doine, l&#039;ex-R\u00e9publique yougoslave de' >Mac\u00e9doine, l&#039;ex-R\u00e9publique yougoslave de<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaisie' >Malaisie<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Iles Marshall' >Iles Marshall<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Maurice' >Maurice<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie, \u00c9tats f\u00e9d\u00e9r\u00e9s de' >Micron\u00e9sie, \u00c9tats f\u00e9d\u00e9r\u00e9s de<\/option><option value='Moldavie, R\u00e9publique de' >Moldavie, R\u00e9publique de<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Maroc' >Maroc<\/option><option value='Mozambique' >Mozambique<\/option><option value='Birmanie' >Birmanie<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Antilles n\u00e9erlandaises' >Antilles n\u00e9erlandaises<\/option><option value='Nouvelle Cal\u00e9donie' >Nouvelle Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niu\u00e9' >Niu\u00e9<\/option><option value='l&#039;ile de Norfolk' >l&#039;ile de Norfolk<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palaos' >Palaos<\/option><option value='Territoire palestinien occup\u00e9' >Territoire palestinien occup\u00e9<\/option><option value='Panama' >Panama<\/option><option value='Papouasie Nouvelle Guin\u00e9e' >Papouasie Nouvelle Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Pologne' >Pologne<\/option><option value='le Portugal' >le Portugal<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Roumanie' >Roumanie<\/option><option value='Russie' >Russie<\/option><option value='Rwanda' >Rwanda<\/option><option value='Sainte-H\u00e9l\u00e8ne' >Sainte-H\u00e9l\u00e8ne<\/option><option value='Saint-Christophe-et-Ni\u00e9v\u00e8s' >Saint-Christophe-et-Ni\u00e9v\u00e8s<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Saint-Pierre-et-Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint-Vincent-et-les-Grenadines' >Saint-Vincent-et-les-Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='Saint Marin' >Saint Marin<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Serbie' >Serbie<\/option><option value='les Seychelles' >les Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Les \u00eeles Salomon' >Les \u00eeles Salomon<\/option><option value='Somalie' >Somalie<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='G\u00e9orgie du Sud et \u00eeles Sandwich du Sud' >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value='Espagne' >Espagne<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Soudan' >Soudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard et Jan Mayen' >Svalbard et Jan Mayen<\/option><option value='Eswatini' >Eswatini<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Suisse' >Suisse<\/option><option value='R\u00e9publique arabe syrienne' >R\u00e9publique arabe syrienne<\/option><option value='Ta\u00efwan (ROC)' >Ta\u00efwan (ROC)<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzanie, R\u00e9publique-Unie de' >Tanzanie, R\u00e9publique-Unie de<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/option><option value='Timor oriental' >Timor oriental<\/option><option value='Aller' >Aller<\/option><option value='Tok\u00e9laou' >Tok\u00e9laou<\/option><option value='Tonga' >Tonga<\/option><option value='Trinit\u00e9-et-Tobago' >Trinit\u00e9-et-Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turquie' >Turquie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='\u00eeles Turques-et-Ca\u00efques' >\u00eeles Turques-et-Ca\u00efques<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='Emirats Arabes Unis' >Emirats Arabes Unis<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='Uruguay' >Uruguay<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vi\u00eat Nam' >Vi\u00eat Nam<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes Vierges, \u00c9tats-Unis' >\u00celes Vierges, \u00c9tats-Unis<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Sahara occidental' >Sahara occidental<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/div><div id=\"field_4_15\" 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_4_15'>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_15' id='input_4_15' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_16\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_16'>Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_4_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_17\" 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_4_17'>Num\u00e9ro de t\u00e9l\u00e9phone cellulaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_4_17' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_95\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_95'>Num\u00e9ro de t\u00e9l\u00e9phone au travail<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_4_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Le meilleur num\u00e9ro pour vous joindre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_19'>\n\t\t\t<div class='gchoice gchoice_4_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Num\u00e9ro pr\u00e9f\u00e9r\u00e9'  id='choice_4_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_19_0' id='label_4_19_0' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro pr\u00e9f\u00e9r\u00e9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison'  id='choice_4_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_19_1' id='label_4_19_1' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Num\u00e9ro de t\u00e9l\u00e9phone au travail'  id='choice_4_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_19_2' id='label_4_19_2' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro de t\u00e9l\u00e9phone au travail<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_20\" class=\"gfield gfield--type-text 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_4_20'>M\u00e9decin de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'>Nom du sp\u00e9cialiste<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_4_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_24\" class=\"gfield gfield--type-text gfield--width-full 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_4_24'>Personne \u00e0 contacter en cas d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_4_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_22\" 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_4_22'>Num\u00e9ro de t\u00e9l\u00e9phone d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_4_22' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Information sur l'assurance<\/h2><\/div><div id=\"field_4_26\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Assurance primaire<\/h4><\/div><fieldset id=\"field_4_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Titulaire d&#039;une police d&#039;assurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_27'>\n\t\t\t<div class='gchoice gchoice_4_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Soi'  id='choice_4_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_0' id='label_4_27_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Conjointe'  id='choice_4_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_1' id='label_4_27_1' class='gform-field-label gform-field-label--type-inline'>Conjointe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Tutrice'  id='choice_4_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_2' id='label_4_27_2' class='gform-field-label gform-field-label--type-inline'>Tutrice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Aucune de ces r\u00e9ponses'  id='choice_4_27_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_3' id='label_4_27_3' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_28\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'>Nom de la compagnie d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_4_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_29'>Nom du titulaire de la police d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_4_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_30\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_30'>Titulaire Date de naissance<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_30' id='input_4_30' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_30_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_30_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_30' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_31\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_31'>Num\u00e9ro de police\/r\u00e9gime collectif<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_4_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_32\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_32'>Num\u00e9ro d&#039;identification\/certificat<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_4_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_33\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Renseignements sur la compagnie d'assurance secondaire<\/h4><\/div><fieldset id=\"field_4_34\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Titulaire d&#039;une police d&#039;assurance<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_34'>\n\t\t\t<div class='gchoice gchoice_4_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Soi'  id='choice_4_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_0' id='label_4_34_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Conjointe'  id='choice_4_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_1' id='label_4_34_1' class='gform-field-label gform-field-label--type-inline'>Conjointe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Tutrice'  id='choice_4_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_2' id='label_4_34_2' class='gform-field-label gform-field-label--type-inline'>Tutrice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Autre'  id='choice_4_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_3' id='label_4_34_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_35\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_35'>Nom de la compagnie d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_4_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_36\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_36'>Nom du titulaire de la police d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_4_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_37\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_37'>Titulaire de la police Date de naissance<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_4_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_38\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_38'>Num\u00e9ro de police\/r\u00e9gime collectif<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_4_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_39\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_39'>Num\u00e9ro d&#039;identification\/certificat<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_4_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_40\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>L'information financi\u00e8re<\/h2><\/div><fieldset id=\"field_4_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Responsable de compte<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_41'>\n\t\t\t<div class='gchoice gchoice_4_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Soi'  id='choice_4_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_0' id='label_4_41_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Conjointe'  id='choice_4_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_1' id='label_4_41_1' class='gform-field-label gform-field-label--type-inline'>Conjointe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Tutrice'  id='choice_4_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_2' id='label_4_41_2' class='gform-field-label gform-field-label--type-inline'>Tutrice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Autre'  id='choice_4_41_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_3' id='label_4_41_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_42\" 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_4_42'>\n                            \n                            <span id='input_4_42_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.3' id='input_4_42_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_4_42_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_4_42_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.6' id='input_4_42_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_4_42_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Mode de paiement pr\u00e9f\u00e9r\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_43'>\n\t\t\t<div class='gchoice gchoice_4_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Interagir'  id='choice_4_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_0' id='label_4_43_0' class='gform-field-label gform-field-label--type-inline'>Interagir<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Visa'  id='choice_4_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_1' id='label_4_43_1' class='gform-field-label gform-field-label--type-inline'>Visa<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Esp\u00e8ces'  id='choice_4_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_2' id='label_4_43_2' class='gform-field-label gform-field-label--type-inline'>Esp\u00e8ces<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Mastercard'  id='choice_4_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_3' id='label_4_43_3' class='gform-field-label gform-field-label--type-inline'>Mastercard<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_44\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Ant\u00e9c\u00e9dents dentaires<\/h2><\/div><div id=\"field_4_45\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_45'>Date de votre dernier examen dentaire<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_4_45' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_45_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_45_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_45' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_46\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_46'>Date de votre dernier nettoyage dentaire<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_46' id='input_4_46' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_46_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_46_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_46' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_47\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_47'>Date de vos derni\u00e8res radiographies dentaires<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_47' id='input_4_47' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_47_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_47_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_47' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Veuillez cocher les probl\u00e8mes suivants qui vous concernent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_48'><div class='gchoice gchoice_4_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Sensibilit\u00e9 (chaud, froid et\/ou sucr\u00e9)'  id='choice_4_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_1' id='label_4_48_1' class='gform-field-label gform-field-label--type-inline'>Sensibilit\u00e9 (chaud, froid et\/ou sucr\u00e9)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='Douleurs dentaires ou g\u00eane lors de la mastication'  id='choice_4_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_2' id='label_4_48_2' class='gform-field-label gform-field-label--type-inline'>Douleurs dentaires ou g\u00eane lors de la mastication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='Maux de t\u00eate, maux d&#039;oreille ou douleurs cervicales'  id='choice_4_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_3' id='label_4_48_3' class='gform-field-label gform-field-label--type-inline'>Maux de t\u00eate, maux d'oreille ou douleurs cervicales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='Douleur \u00e0 l&#039;articulation de la m\u00e2choire (claquement\/craquement)'  id='choice_4_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_4' id='label_4_48_4' class='gform-field-label gform-field-label--type-inline'>Douleur \u00e0 l'articulation de la m\u00e2choire (claquement\/craquement)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.5' type='checkbox'  value='Grincement ou serrement de dents'  id='choice_4_48_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_5' id='label_4_48_5' class='gform-field-label gform-field-label--type-inline'>Grincement ou serrement de dents<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.6' type='checkbox'  value='Saignement, gonflement ou irritation des gencives'  id='choice_4_48_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_6' id='label_4_48_6' class='gform-field-label gform-field-label--type-inline'>Saignement, gonflement ou irritation des gencives<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.7' type='checkbox'  value='Dents d\u00e9chauss\u00e9es, \u00e9br\u00e9ch\u00e9es ou d\u00e9plac\u00e9es'  id='choice_4_48_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_7' id='label_4_48_7' class='gform-field-label gform-field-label--type-inline'>Dents d\u00e9chauss\u00e9es, \u00e9br\u00e9ch\u00e9es ou d\u00e9plac\u00e9es<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.8' type='checkbox'  value='Mauvaise haleine ou mauvais go\u00fbt dans la bouche'  id='choice_4_48_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_8' id='label_4_48_8' class='gform-field-label gform-field-label--type-inline'>Mauvaise haleine ou mauvais go\u00fbt dans la bouche<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.9' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_48_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_9' id='label_4_48_9' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Souffrez-vous ou avez-vous souffert de l&#039;un des probl\u00e8mes suivants ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_49'><div class='gchoice gchoice_4_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Proth\u00e8ses dentaires'  id='choice_4_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_1' id='label_4_49_1' class='gform-field-label gform-field-label--type-inline'>Proth\u00e8ses dentaires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Orthodontie'  id='choice_4_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_2' id='label_4_49_2' class='gform-field-label gform-field-label--type-inline'>Orthodontie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Proth\u00e8ses dentaires partielles'  id='choice_4_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_3' id='label_4_49_3' class='gform-field-label gform-field-label--type-inline'>Proth\u00e8ses dentaires partielles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Traitements parodontaux (gencives)'  id='choice_4_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_4' id='label_4_49_4' class='gform-field-label gform-field-label--type-inline'>Traitements parodontaux (gencives)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.5' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_49_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_5' id='label_4_49_5' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si vous pouviez changer votre sourire, vous le feriez...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_50'><div class='gchoice gchoice_4_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Rendre vos dents plus brillantes'  id='choice_4_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_1' id='label_4_50_1' class='gform-field-label gform-field-label--type-inline'>Rendre vos dents plus brillantes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Rendre vos dents plus droites'  id='choice_4_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_2' id='label_4_50_2' class='gform-field-label gform-field-label--type-inline'>Rendre vos dents plus droites<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Combler les \u00e9carts entre les dents'  id='choice_4_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_3' id='label_4_50_3' class='gform-field-label gform-field-label--type-inline'>Combler les \u00e9carts entre les dents<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Remplacer les obturations m\u00e9talliques par des obturations naturelles de la couleur des dents'  id='choice_4_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_4' id='label_4_50_4' class='gform-field-label gform-field-label--type-inline'>Remplacer les obturations m\u00e9talliques par des obturations naturelles de la couleur des dents<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.5' type='checkbox'  value='R\u00e9parer les dents \u00e9br\u00e9ch\u00e9es'  id='choice_4_50_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_5' id='label_4_50_5' class='gform-field-label gform-field-label--type-inline'>R\u00e9parer les dents \u00e9br\u00e9ch\u00e9es<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.6' type='checkbox'  value='Remplacer les dents manquantes'  id='choice_4_50_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_6' id='label_4_50_6' class='gform-field-label gform-field-label--type-inline'>Remplacer les dents manquantes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.7' type='checkbox'  value='Remplacer les vieilles couronnes qui ne sont pas assorties'  id='choice_4_50_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_7' id='label_4_50_7' class='gform-field-label gform-field-label--type-inline'>Remplacer les vieilles couronnes qui ne sont pas assorties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.8' type='checkbox'  value='Transformer le sourire'  id='choice_4_50_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_8' id='label_4_50_8' class='gform-field-label gform-field-label--type-inline'>Transformer le sourire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.9' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_50_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_9' id='label_4_50_9' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Quelle est l&#039;importance de votre sant\u00e9 dentaire pour vous?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_51'>\n\t\t\t<div class='gchoice gchoice_4_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='1'  id='choice_4_51_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_4_51\"   \/>\n\t\t\t\t\t<label for='choice_4_51_0' id='label_4_51_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='2'  id='choice_4_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_1' id='label_4_51_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='3'  id='choice_4_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_2' id='label_4_51_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='4'  id='choice_4_51_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_3' id='label_4_51_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='5'  id='choice_4_51_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_4' id='label_4_51_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='6'  id='choice_4_51_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_5' id='label_4_51_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='7'  id='choice_4_51_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_6' id='label_4_51_6' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='8'  id='choice_4_51_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_7' id='label_4_51_7' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='9'  id='choice_4_51_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_8' id='label_4_51_8' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='10'  id='choice_4_51_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_9' id='label_4_51_9' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_4_51'><small>Sur une \u00e9chelle de 1 \u00e0 10, 10 \u00e9tant la note la plus \u00e9lev\u00e9e<\/small><\/div><\/fieldset><fieldset id=\"field_4_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Comment \u00e9valueriez-vous votre sant\u00e9 dentaire actuelle ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_52'>\n\t\t\t<div class='gchoice gchoice_4_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='1'  id='choice_4_52_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_4_52\"   \/>\n\t\t\t\t\t<label for='choice_4_52_0' id='label_4_52_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='2'  id='choice_4_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_1' id='label_4_52_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='3'  id='choice_4_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_2' id='label_4_52_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='4'  id='choice_4_52_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_3' id='label_4_52_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='5'  id='choice_4_52_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_4' id='label_4_52_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='6'  id='choice_4_52_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_5' id='label_4_52_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='7'  id='choice_4_52_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_6' id='label_4_52_6' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='8'  id='choice_4_52_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_7' id='label_4_52_7' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='9'  id='choice_4_52_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_8' id='label_4_52_8' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='10'  id='choice_4_52_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_9' id='label_4_52_9' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_4_52'><small>Sur une \u00e9chelle de 1 \u00e0 10, 10 \u00e9tant la note la plus \u00e9lev\u00e9e<\/small><\/div><\/fieldset><div id=\"field_4_53\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_53'>Pourquoi quittez-vous votre ancien dentiste ?<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_4_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_54\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Dans le pass\u00e9, qu&#039;est-ce qui vous a emp\u00each\u00e9 d&#039;avoir des soins dentaires ?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_55\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_55'>Quelle est la chose la plus importante concernant votre futur sourire et votre sant\u00e9 dentaire ?<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_4_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_56\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_56'>Quelle est la chose la plus importante pour vous concernant votre prochaine visite ?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_4_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_57\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Ant\u00e9c\u00e9dents m\u00e9dicaux<\/h2><\/div><div id=\"field_4_58\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Les informations suivantes sont n\u00e9cessaires pour nous permettre de vous fournir les meilleurs soins dentaires possibles. Toutes les informations sont strictement priv\u00e9es et sont prot\u00e9g\u00e9es par la confidentialit\u00e9 m\u00e9decin-patient. Le dentiste examinera les questions et expliquera celles que vous ne comprenez pas. Veuillez remplir le formulaire en entier.<\/div><fieldset id=\"field_4_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00cates-vous actuellement trait\u00e9 pour une condition m\u00e9dicale ou avez-vous \u00e9t\u00e9 trait\u00e9 au cours de la derni\u00e8re ann\u00e9e ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_59'>\n\t\t\t<div class='gchoice gchoice_4_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Oui'  id='choice_4_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_59_0' id='label_4_59_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Non'  id='choice_4_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_59_1' id='label_4_59_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_92\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_92'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_92' id='input_4_92' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Y a-t-il eu des changements dans votre \u00e9tat de sant\u00e9 g\u00e9n\u00e9ral au cours de la derni\u00e8re ann\u00e9e ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_60'>\n\t\t\t<div class='gchoice gchoice_4_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Oui'  id='choice_4_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_60_0' id='label_4_60_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Non'  id='choice_4_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_91\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_91'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_91' id='input_4_91' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Prenez-vous des m\u00e9dicaments, des m\u00e9dicaments sans ordonnance ou des suppl\u00e9ments \u00e0 base de plantes de toute sorte ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_61'>\n\t\t\t<div class='gchoice gchoice_4_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Oui'  id='choice_4_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_61_0' id='label_4_61_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non'  id='choice_4_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_61_1' id='label_4_61_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_90\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_90'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_90' id='input_4_90' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >As tu des allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_62'>\n\t\t\t<div class='gchoice gchoice_4_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Oui'  id='choice_4_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_0' id='label_4_62_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Non'  id='choice_4_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_1' id='label_4_62_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_89\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_89'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_89' id='input_4_89' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 eu une r\u00e9action particuli\u00e8re ou ind\u00e9sirable \u00e0 des m\u00e9dicaments ou \u00e0 des injections ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_63'>\n\t\t\t<div class='gchoice gchoice_4_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Oui'  id='choice_4_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_63_0' id='label_4_63_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Non'  id='choice_4_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_63_1' id='label_4_63_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_88\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_88'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_4_88' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu de l&#039;asthme?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_64'>\n\t\t\t<div class='gchoice gchoice_4_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Oui'  id='choice_4_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_0' id='label_4_64_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Non'  id='choice_4_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_1' id='label_4_64_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu des probl\u00e8mes cardiaques ou de pression art\u00e9rielle ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_65'>\n\t\t\t<div class='gchoice gchoice_4_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Oui'  id='choice_4_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_65_0' id='label_4_65_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Non'  id='choice_4_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_65_1' id='label_4_65_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_96\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_96'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_96' id='input_4_96' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu un remplacement ou une r\u00e9paration d&#039;une valve cardiaque, une infection du c\u0153ur (c.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_66'>\n\t\t\t<div class='gchoice gchoice_4_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Oui'  id='choice_4_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_66_0' id='label_4_66_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Non'  id='choice_4_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_66_1' id='label_4_66_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_87\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_87' id='input_4_87' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous une articulation proth\u00e9tique ou artificielle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_67'>\n\t\t\t<div class='gchoice gchoice_4_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Oui'  id='choice_4_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_67_0' id='label_4_67_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Non'  id='choice_4_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_67_1' id='label_4_67_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_86\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_86'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_86' id='input_4_86' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous des conditions ou des traitements qui pourraient affecter votre syst\u00e8me immunitaire (par exemple, la leuc\u00e9mie, le SIDA, l&#039;infection par le VIH, la radioth\u00e9rapie, la chimioth\u00e9rapie) ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_68'>\n\t\t\t<div class='gchoice gchoice_4_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Oui'  id='choice_4_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_68_0' id='label_4_68_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Non'  id='choice_4_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_68_1' id='label_4_68_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_85\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_85'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_4_85' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 pour une maladie ou une op\u00e9ration ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_69'>\n\t\t\t<div class='gchoice gchoice_4_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Oui'  id='choice_4_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_69_0' id='label_4_69_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Non'  id='choice_4_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_69_1' id='label_4_69_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_84\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_84'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_84' id='input_4_84' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu l&#039;un des probl\u00e8mes suivants ? Veuillez cocher tout ce qui s&#039;applique.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_72'><div class='gchoice gchoice_4_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='douleur thoracique, angine'  id='choice_4_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_1' id='label_4_72_1' class='gform-field-label gform-field-label--type-inline'>douleur thoracique, angine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='rhumatisme articulaire aigu'  id='choice_4_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_2' id='label_4_72_2' class='gform-field-label gform-field-label--type-inline'>rhumatisme articulaire aigu<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.3' type='checkbox'  value='stimulateur cardiaque'  id='choice_4_72_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_3' id='label_4_72_3' class='gform-field-label gform-field-label--type-inline'>stimulateur cardiaque<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.4' type='checkbox'  value='corticoth\u00e9rapie'  id='choice_4_72_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_4' id='label_4_72_4' class='gform-field-label gform-field-label--type-inline'>corticoth\u00e9rapie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.5' type='checkbox'  value='convulsions (\u00e9pilepsie)'  id='choice_4_72_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_5' id='label_4_72_5' class='gform-field-label gform-field-label--type-inline'>convulsions (\u00e9pilepsie)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.6' type='checkbox'  value='crise cardiaque'  id='choice_4_72_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_6' id='label_4_72_6' class='gform-field-label gform-field-label--type-inline'>crise cardiaque<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.7' type='checkbox'  value='prolapsus de la valve mitrale'  id='choice_4_72_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_7' id='label_4_72_7' class='gform-field-label gform-field-label--type-inline'>prolapsus de la valve mitrale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.8' type='checkbox'  value='les maladies pulmonaires'  id='choice_4_72_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_8' id='label_4_72_8' class='gform-field-label gform-field-label--type-inline'>les maladies pulmonaires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.9' type='checkbox'  value='diab\u00e8te'  id='choice_4_72_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_9' id='label_4_72_9' class='gform-field-label gform-field-label--type-inline'>diab\u00e8te<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.11' type='checkbox'  value='maladie du rein'  id='choice_4_72_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_11' id='label_4_72_11' class='gform-field-label gform-field-label--type-inline'>maladie du rein<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.12' type='checkbox'  value='accident vasculaire c\u00e9r\u00e9bral, AIT'  id='choice_4_72_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_12' id='label_4_72_12' class='gform-field-label gform-field-label--type-inline'>accident vasculaire c\u00e9r\u00e9bral, AIT<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.13' type='checkbox'  value='tuberculose'  id='choice_4_72_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_13' id='label_4_72_13' class='gform-field-label gform-field-label--type-inline'>tuberculose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.14' type='checkbox'  value='ulc\u00e8res d&#039;estomac'  id='choice_4_72_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_14' id='label_4_72_14' class='gform-field-label gform-field-label--type-inline'>ulc\u00e8res d'estomac<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.15' type='checkbox'  value='maladie thyro\u00efdienne'  id='choice_4_72_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_15' id='label_4_72_15' class='gform-field-label gform-field-label--type-inline'>maladie thyro\u00efdienne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.16' type='checkbox'  value='essoufflement'  id='choice_4_72_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_16' id='label_4_72_16' class='gform-field-label gform-field-label--type-inline'>essoufflement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.17' type='checkbox'  value='souffle au coeur'  id='choice_4_72_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_17' id='label_4_72_17' class='gform-field-label gform-field-label--type-inline'>souffle au coeur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.18' type='checkbox'  value='cancer'  id='choice_4_72_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_18' id='label_4_72_18' class='gform-field-label gform-field-label--type-inline'>cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.19' type='checkbox'  value='arthrite'  id='choice_4_72_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_19' id='label_4_72_19' class='gform-field-label gform-field-label--type-inline'>arthrite<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.21' type='checkbox'  value='consommation de drogue\/alcool\/cannabis ou d\u00e9pendance'  id='choice_4_72_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_21' id='label_4_72_21' class='gform-field-label gform-field-label--type-inline'>consommation de drogue\/alcool\/cannabis ou d\u00e9pendance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.22' type='checkbox'  value='m\u00e9dicaments contre l&#039;ost\u00e9oporose (par exemple Fosamax, Actonel)'  id='choice_4_72_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_22' id='label_4_72_22' class='gform-field-label gform-field-label--type-inline'>m\u00e9dicaments contre l'ost\u00e9oporose (par exemple Fosamax, Actonel)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.23' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_72_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_23' id='label_4_72_23' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Y a-t-il des conditions ou des maladies non \u00e9num\u00e9r\u00e9es ci-dessus que vous avez ou avez eues ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_73'>\n\t\t\t<div class='gchoice gchoice_4_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Oui'  id='choice_4_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_73_0' id='label_4_73_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Non'  id='choice_4_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_73_1' id='label_4_73_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_83\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_83'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_4_83' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Fumez-vous ou utilisez-vous d&#039;autres produits \u00e0 base de nicotine ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_74'>\n\t\t\t<div class='gchoice gchoice_4_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Oui'  id='choice_4_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_74_0' id='label_4_74_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Non'  id='choice_4_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_74_1' id='label_4_74_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Vous allaitez ou \u00eates enceinte ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_75'>\n\t\t\t<div class='gchoice gchoice_4_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Oui'  id='choice_4_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_75_0' id='label_4_75_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Non'  id='choice_4_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_75_1' id='label_4_75_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_100\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_100'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_4_100' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous un handicap ou \u00eates-vous une personne ayant une d\u00e9ficience visuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_76'>\n\t\t\t<div class='gchoice gchoice_4_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Oui'  id='choice_4_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_76_0' id='label_4_76_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Non'  id='choice_4_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_76_1' id='label_4_76_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_82\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_82'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_4_82' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_77\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Publication g\u00e9n\u00e9rale<\/h2><\/div><fieldset id=\"field_4_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >J&#039;accepte votre politique d&#039;annulation et je comprends qu&#039;un pr\u00e9avis de deux (2) jours ouvrables est requis pour reporter mon rendez-vous.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_78'>\n\t\t\t<div class='gchoice gchoice_4_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Je suis d&#039;accord'  id='choice_4_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_78_0' id='label_4_78_0' class='gform-field-label gform-field-label--type-inline'>Je suis d'accord<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Je ne suis pas d&#039;accord'  id='choice_4_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_78_1' id='label_4_78_1' class='gform-field-label gform-field-label--type-inline'>Je ne suis pas d'accord<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_93\" 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>Je, soussign\u00e9, certifie avoir fourni un historique personnel et m\u00e9dico-dentaire exact et complet et n'avoir sciemment omis aucune information. J'ai eu la chance de poser des questions et d'obtenir des r\u00e9ponses \u00e0 toute question concernant mes ant\u00e9c\u00e9dents m\u00e9dico-dentaires. J'autorise le dentiste \u00e0 effectuer les proc\u00e9dures de diagnostic n\u00e9cessaires pour d\u00e9terminer le traitement requis. Je comprends que les informations fournies par ou \u00e0 mon m\u00e9decin ou \u00e0 un autre professionnel de la sant\u00e9 peuvent \u00eatre n\u00e9cessaires, et je consens \u00e0 ce que ces informations soient fournies. Je comprends que la responsabilit\u00e9 du paiement des services dentaires pour moi-m\u00eame et les personnes \u00e0 ma charge est mienne, et j'assume la responsabilit\u00e9 des frais associ\u00e9s \u00e0 ces services. J'accepte que la relation entre moi-m\u00eame et le dentiste soit r\u00e9gie et interpr\u00e9t\u00e9e conform\u00e9ment aux lois de la province de l'Ontario.<\/p><\/div><div id=\"field_4_79\" 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_4_79'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_79' id='input_4_79_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_4_79_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_4_79' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_4_79_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_4_79_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_4_79_data' name='input_4_79_data' value=''><\/div><div class='gfield_description' id='gfield_description_4_79'><small>Utilisez votre souris ou votre doigt pour dessiner votre signature ci-dessus<\/small><\/div><\/div><div id=\"field_4_80\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_80'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_4_80' type='text' value='07\/28\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_80_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_80_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_80' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre'  \/> <input type='hidden' name='gform_ajax' value='form_id=4&amp;title=1&amp;description=1&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=50b2f0b460d781cda9747a0dd2a2e350' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='gezvJQX3itubUYpeWYvU0BpSK+1Hext1zjNNJEmu4RC4kNvsKJx2v7f4rkLnMRcpwWcth6BtgWBPNY54HAX3kUGgxOWMv4NCNNk1EF86C20SMX4=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' 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\/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_4' id='gform_target_page_number_4' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_4' id='gform_source_page_number_4' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_4' id='gform_ajax_frame_4' title='Cette iframe contient la logique n\u00e9cessaire pour manipuler Gravity Forms avec Ajax.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 4, 'https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_4').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_4');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_4').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_4').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_4').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_4').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_4').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_4').val();gformInitSpinner( 4, 'https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [4, current_page]);window['gf_submitting_4'] = 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_4').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_4').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [4]);window['gf_submitting_4'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_4').text());}else{jQuery('#gform_4').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"4\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_4\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_4\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_4\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 4, 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' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Formulaire d\u2019ant\u00e9c\u00e9dents m\u00e9dicaux du nouveau patient\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_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">NOUVEAU FORMULAIRE PATIENT<\/h2>\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_4' id='gform_4'  action='\/fr\/wp-json\/wp\/v2\/pages\/5184#gf_4' data-formid='4' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeCWBUiAAAAANv34xcxvYKHX6-NK2IdU12ogpU2' data-tabindex='0'><input id=\"input_1c9cb9763a57953039690a5d3630d98b\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_1c9cb9763a57953039690a5d3630d98b\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_97\" class=\"gfield gfield--type-select gfield--width-full 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_4_97'>Comment avez-vous entendu parler de notre clinique dentaire?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_4_97' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >S\u00e9lectionner<\/option><option value='Renvoi de patient' >Renvoi de patient<\/option><option value='R\u00e9side dans la r\u00e9gion' >R\u00e9side dans la r\u00e9gion<\/option><option value='Travaille \u00e0 proximit\u00e9' >Travaille \u00e0 proximit\u00e9<\/option><option value='Radio' >Radio<\/option><option value='M\u00e9diaux sociaux' >M\u00e9diaux sociaux<\/option><option value='Autres' >Autre<\/option><\/select><\/div><\/div><div id=\"field_4_99\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_99'>Donnez quelques d\u00e9tails :<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_99' id='input_4_99' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_3\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2> Coordonn\u00e9es des patients <\/h2><\/div><div id=\"field_4_81\" class=\"gfield gfield--type-select gfield--width-full 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_4_81'>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_81' id='input_4_81' 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_4_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_4_5'>\n                            \n                            <span id='input_4_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_4_5_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_4_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_4_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_4_5_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_4_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><fieldset id=\"field_4_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Genre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_6'>\n\t\t\t<div class='gchoice gchoice_4_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='M\u00e2le'  id='choice_4_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_0' id='label_4_6_0' class='gform-field-label gform-field-label--type-inline'>M\u00e2le<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Femme'  id='choice_4_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_1' id='label_4_6_1' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_6_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Autre'  id='choice_4_6_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_6_2' id='label_4_6_2' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_101\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_101'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_4_101' type='text' value='' class='large'    placeholder='Donnez quelques d\u00e9tails'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_7\" class=\"gfield gfield--type-name gfield_contains_required 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<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/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_4_7'>\n                            \n                            <span id='input_4_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_4_7_3' value=''   aria-required='true'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_4_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_4_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_4_7_6' value=''   aria-required='true'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_4_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_4_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_4_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_4_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_8_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_8' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_9\" class=\"gfield gfield--type-address gfield_contains_required 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' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_4_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_4_9_1' value=''   placeholder='Adresse 1' aria-required='true'    \/>\n                                        <label for='input_4_9_1' id='input_4_9_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Adresse postale<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_9.4' id='input_4_9_4' value=''\/><input type='hidden' class='gform_hidden' name='input_9.6' id='input_4_9_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_4_12\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_12'>Ville<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_4_12' type='text' value='' class='large'    placeholder='Ville' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_10\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_10'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_4_10' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='S\u00e9lectionnez la province' >S\u00e9lectionnez la province<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie britannique' >Colombie britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du nord-ouest' >Territoires du nord-ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select><\/div><\/div><div id=\"field_4_13\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'>Code Postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_4_13' type='text' value='' class='large'    placeholder='Code Postal' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_14\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Pays<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_4_14' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Choisissez le pays' >Choisissez le pays<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Iles Aland' >Iles Aland<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='L&#039;Autriche' >L&#039;Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bengladesh' >Bengladesh<\/option><option value='Barbade' >Barbade<\/option><option value='Bi\u00e9lorussie' >Bi\u00e9lorussie<\/option><option value='Belgique' >Belgique<\/option><option value='B\u00e9lize' >B\u00e9lize<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bosnie Herz\u00e9govine' >Bosnie Herz\u00e9govine<\/option><option value='Bostwana' >Bostwana<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Territoire britannique de l&#039;oc\u00e9an Indien' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='\u00celes Ca\u00efmans' >\u00celes Ca\u00efmans<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='Tchad' >Tchad<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='L&#039;\u00eele de no\u00ebl' >L&#039;\u00eele de no\u00ebl<\/option><option value='\u00celes Cocos (Keeling)' >\u00celes Cocos (Keeling)<\/option><option value='Colombie&quot; &quot;Comores' >Colombie&quot; &quot;Comores<\/option><option value='Congo' >Congo<\/option><option value='Congo, R\u00e9publique D\u00e9mocratique du' >Congo, R\u00e9publique D\u00e9mocratique du<\/option><option value='les \u00celes Cook' >les \u00celes Cook<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te D&#039;ivoire' >C\u00f4te D&#039;ivoire<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Chypre' >Chypre<\/option><option value='R\u00e9publique tch\u00e8que' >R\u00e9publique tch\u00e8que<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='R\u00e9publique dominicaine' >R\u00e9publique dominicaine<\/option><option value='Equateur' >Equateur<\/option><option value='Egypte' >Egypte<\/option><option value='Le Salvador' >Le Salvador<\/option><option value='Guin\u00e9e \u00c9quatoriale' >Guin\u00e9e \u00c9quatoriale<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='Estonie' >Estonie<\/option><option value='Ethiopie' >Ethiopie<\/option><option value='\u00celes Falkland (Malouines)' >\u00celes Falkland (Malouines)<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='Guyane Fran\u00e7aise' >Guyane Fran\u00e7aise<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Terres australes fran\u00e7aises' >Terres australes fran\u00e7aises<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Groenland' >Groenland<\/option><option value='Grenade' >Grenade<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernesey' >Guernesey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e-bissau' >Guin\u00e9e-bissau<\/option><option value='Guyane' >Guyane<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='\u00cele Heard et \u00celes Mcdonald' >\u00cele Heard et \u00celes Mcdonald<\/option><option value='Saint-Si\u00e8ge (\u00c9tat de la Cit\u00e9 du Vatican)' >Saint-Si\u00e8ge (\u00c9tat de la Cit\u00e9 du Vatican)<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Islande' >Islande<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Iran (R\u00e9publique islamique d' >Iran (R\u00e9publique islamique d<\/option><option value='Irak' >Irak<\/option><option value='Irlande' >Irlande<\/option><option value='\u00eele de Man' >\u00eele de Man<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='R\u00e9publique populaire d\u00e9mocratique de Cor\u00e9e' >R\u00e9publique populaire d\u00e9mocratique de Cor\u00e9e<\/option><option value='Cor\u00e9e, R\u00e9publique de' >Cor\u00e9e, R\u00e9publique de<\/option><option value='Koweit' >Koweit<\/option><option value='Kirghizistan' >Kirghizistan<\/option><option value='R\u00e9publique d\u00e9mocratique populaire lao' >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lib\u00e9ria' >Lib\u00e9ria<\/option><option value='Jamahiriya arabe libyenne' >Jamahiriya arabe libyenne<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Mac\u00e9doine, l&#039;ex-R\u00e9publique yougoslave de' >Mac\u00e9doine, l&#039;ex-R\u00e9publique yougoslave de<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaisie' >Malaisie<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Iles Marshall' >Iles Marshall<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Maurice' >Maurice<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie, \u00c9tats f\u00e9d\u00e9r\u00e9s de' >Micron\u00e9sie, \u00c9tats f\u00e9d\u00e9r\u00e9s de<\/option><option value='Moldavie, R\u00e9publique de' >Moldavie, R\u00e9publique de<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Maroc' >Maroc<\/option><option value='Mozambique' >Mozambique<\/option><option value='Birmanie' >Birmanie<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Antilles n\u00e9erlandaises' >Antilles n\u00e9erlandaises<\/option><option value='Nouvelle Cal\u00e9donie' >Nouvelle Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niu\u00e9' >Niu\u00e9<\/option><option value='l&#039;ile de Norfolk' >l&#039;ile de Norfolk<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palaos' >Palaos<\/option><option value='Territoire palestinien occup\u00e9' >Territoire palestinien occup\u00e9<\/option><option value='Panama' >Panama<\/option><option value='Papouasie Nouvelle Guin\u00e9e' >Papouasie Nouvelle Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Pologne' >Pologne<\/option><option value='le Portugal' >le Portugal<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Roumanie' >Roumanie<\/option><option value='Russie' >Russie<\/option><option value='Rwanda' >Rwanda<\/option><option value='Sainte-H\u00e9l\u00e8ne' >Sainte-H\u00e9l\u00e8ne<\/option><option value='Saint-Christophe-et-Ni\u00e9v\u00e8s' >Saint-Christophe-et-Ni\u00e9v\u00e8s<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Saint-Pierre-et-Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint-Vincent-et-les-Grenadines' >Saint-Vincent-et-les-Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='Saint Marin' >Saint Marin<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Serbie' >Serbie<\/option><option value='les Seychelles' >les Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Les \u00eeles Salomon' >Les \u00eeles Salomon<\/option><option value='Somalie' >Somalie<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='G\u00e9orgie du Sud et \u00eeles Sandwich du Sud' >G\u00e9orgie du Sud et \u00eeles Sandwich du Sud<\/option><option value='Espagne' >Espagne<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Soudan' >Soudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard et Jan Mayen' >Svalbard et Jan Mayen<\/option><option value='Eswatini' >Eswatini<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='Suisse' >Suisse<\/option><option value='R\u00e9publique arabe syrienne' >R\u00e9publique arabe syrienne<\/option><option value='Ta\u00efwan (ROC)' >Ta\u00efwan (ROC)<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzanie, R\u00e9publique-Unie de' >Tanzanie, R\u00e9publique-Unie de<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/option><option value='Timor oriental' >Timor oriental<\/option><option value='Aller' >Aller<\/option><option value='Tok\u00e9laou' >Tok\u00e9laou<\/option><option value='Tonga' >Tonga<\/option><option value='Trinit\u00e9-et-Tobago' >Trinit\u00e9-et-Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turquie' >Turquie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='\u00eeles Turques-et-Ca\u00efques' >\u00eeles Turques-et-Ca\u00efques<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='Emirats Arabes Unis' >Emirats Arabes Unis<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='Uruguay' >Uruguay<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vi\u00eat Nam' >Vi\u00eat Nam<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes Vierges, \u00c9tats-Unis' >\u00celes Vierges, \u00c9tats-Unis<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Sahara occidental' >Sahara occidental<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/div><div id=\"field_4_15\" 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_4_15'>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_15' id='input_4_15' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_16\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_16'>Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_4_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_17\" 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_4_17'>Num\u00e9ro de t\u00e9l\u00e9phone cellulaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_4_17' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_95\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_95'>Num\u00e9ro de t\u00e9l\u00e9phone au travail<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_4_95' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Le meilleur num\u00e9ro pour vous joindre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_19'>\n\t\t\t<div class='gchoice gchoice_4_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Num\u00e9ro pr\u00e9f\u00e9r\u00e9'  id='choice_4_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_19_0' id='label_4_19_0' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro pr\u00e9f\u00e9r\u00e9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison'  id='choice_4_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_19_1' id='label_4_19_1' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro de t\u00e9l\u00e9phone \u00e0 la maison<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_19_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Num\u00e9ro de t\u00e9l\u00e9phone au travail'  id='choice_4_19_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_19_2' id='label_4_19_2' class='gform-field-label gform-field-label--type-inline'>Num\u00e9ro de t\u00e9l\u00e9phone au travail<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_20\" class=\"gfield gfield--type-text 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_4_20'>M\u00e9decin de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_4_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_21\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'>Nom du sp\u00e9cialiste<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_4_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_24\" class=\"gfield gfield--type-text gfield--width-full 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_4_24'>Personne \u00e0 contacter en cas d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_4_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_22\" 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_4_22'>Num\u00e9ro de t\u00e9l\u00e9phone d&#039;urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_4_22' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Information sur l'assurance<\/h2><\/div><div id=\"field_4_26\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Assurance primaire<\/h4><\/div><fieldset id=\"field_4_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Titulaire d&#039;une police d&#039;assurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_27'>\n\t\t\t<div class='gchoice gchoice_4_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Soi'  id='choice_4_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_0' id='label_4_27_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Conjointe'  id='choice_4_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_1' id='label_4_27_1' class='gform-field-label gform-field-label--type-inline'>Conjointe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Tutrice'  id='choice_4_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_2' id='label_4_27_2' class='gform-field-label gform-field-label--type-inline'>Tutrice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Aucune de ces r\u00e9ponses'  id='choice_4_27_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_3' id='label_4_27_3' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_28\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'>Nom de la compagnie d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_4_28' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_29\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_29'>Nom du titulaire de la police d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_4_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_30\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_30'>Titulaire Date de naissance<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_30' id='input_4_30' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_30_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_30_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_30' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_31\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_31'>Num\u00e9ro de police\/r\u00e9gime collectif<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_4_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_32\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_32'>Num\u00e9ro d&#039;identification\/certificat<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_4_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_33\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Renseignements sur la compagnie d'assurance secondaire<\/h4><\/div><fieldset id=\"field_4_34\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Titulaire d&#039;une police d&#039;assurance<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_34'>\n\t\t\t<div class='gchoice gchoice_4_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Soi'  id='choice_4_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_0' id='label_4_34_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Conjointe'  id='choice_4_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_1' id='label_4_34_1' class='gform-field-label gform-field-label--type-inline'>Conjointe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Tutrice'  id='choice_4_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_2' id='label_4_34_2' class='gform-field-label gform-field-label--type-inline'>Tutrice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Autre'  id='choice_4_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_34_3' id='label_4_34_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_35\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_35'>Nom de la compagnie d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_4_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_36\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_36'>Nom du titulaire de la police d&#039;assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_4_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_37\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_37'>Titulaire de la police Date de naissance<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_4_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_38\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_38'>Num\u00e9ro de police\/r\u00e9gime collectif<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_4_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_39\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_39'>Num\u00e9ro d&#039;identification\/certificat<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_4_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_40\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>L'information financi\u00e8re<\/h2><\/div><fieldset id=\"field_4_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Responsable de compte<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_41'>\n\t\t\t<div class='gchoice gchoice_4_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Soi'  id='choice_4_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_0' id='label_4_41_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Conjointe'  id='choice_4_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_1' id='label_4_41_1' class='gform-field-label gform-field-label--type-inline'>Conjointe<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Tutrice'  id='choice_4_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_2' id='label_4_41_2' class='gform-field-label gform-field-label--type-inline'>Tutrice<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Autre'  id='choice_4_41_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_41_3' id='label_4_41_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_42\" 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_4_42'>\n                            \n                            <span id='input_4_42_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.3' id='input_4_42_3' value=''   aria-required='false'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_4_42_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_4_42_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.6' id='input_4_42_6' value=''   aria-required='false'   placeholder='Nom de famille'  \/>\n                                                    <label for='input_4_42_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_4_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Mode de paiement pr\u00e9f\u00e9r\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_43'>\n\t\t\t<div class='gchoice gchoice_4_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Interagir'  id='choice_4_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_0' id='label_4_43_0' class='gform-field-label gform-field-label--type-inline'>Interagir<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Visa'  id='choice_4_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_1' id='label_4_43_1' class='gform-field-label gform-field-label--type-inline'>Visa<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Esp\u00e8ces'  id='choice_4_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_2' id='label_4_43_2' class='gform-field-label gform-field-label--type-inline'>Esp\u00e8ces<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Mastercard'  id='choice_4_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_43_3' id='label_4_43_3' class='gform-field-label gform-field-label--type-inline'>Mastercard<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_44\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Ant\u00e9c\u00e9dents dentaires<\/h2><\/div><div id=\"field_4_45\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_45'>Date de votre dernier examen dentaire<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_45' id='input_4_45' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_45_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_45_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_45' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_46\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_46'>Date de votre dernier nettoyage dentaire<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_46' id='input_4_46' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_46_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_46_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_46' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_47\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_47'>Date de vos derni\u00e8res radiographies dentaires<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_47' id='input_4_47' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_47_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_47_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_47' class='gform_hidden' value='https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Veuillez cocher les probl\u00e8mes suivants qui vous concernent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_48'><div class='gchoice gchoice_4_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Sensibilit\u00e9 (chaud, froid et\/ou sucr\u00e9)'  id='choice_4_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_1' id='label_4_48_1' class='gform-field-label gform-field-label--type-inline'>Sensibilit\u00e9 (chaud, froid et\/ou sucr\u00e9)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='Douleurs dentaires ou g\u00eane lors de la mastication'  id='choice_4_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_2' id='label_4_48_2' class='gform-field-label gform-field-label--type-inline'>Douleurs dentaires ou g\u00eane lors de la mastication<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='Maux de t\u00eate, maux d&#039;oreille ou douleurs cervicales'  id='choice_4_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_3' id='label_4_48_3' class='gform-field-label gform-field-label--type-inline'>Maux de t\u00eate, maux d'oreille ou douleurs cervicales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='Douleur \u00e0 l&#039;articulation de la m\u00e2choire (claquement\/craquement)'  id='choice_4_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_4' id='label_4_48_4' class='gform-field-label gform-field-label--type-inline'>Douleur \u00e0 l'articulation de la m\u00e2choire (claquement\/craquement)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.5' type='checkbox'  value='Grincement ou serrement de dents'  id='choice_4_48_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_5' id='label_4_48_5' class='gform-field-label gform-field-label--type-inline'>Grincement ou serrement de dents<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.6' type='checkbox'  value='Saignement, gonflement ou irritation des gencives'  id='choice_4_48_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_6' id='label_4_48_6' class='gform-field-label gform-field-label--type-inline'>Saignement, gonflement ou irritation des gencives<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.7' type='checkbox'  value='Dents d\u00e9chauss\u00e9es, \u00e9br\u00e9ch\u00e9es ou d\u00e9plac\u00e9es'  id='choice_4_48_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_7' id='label_4_48_7' class='gform-field-label gform-field-label--type-inline'>Dents d\u00e9chauss\u00e9es, \u00e9br\u00e9ch\u00e9es ou d\u00e9plac\u00e9es<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.8' type='checkbox'  value='Mauvaise haleine ou mauvais go\u00fbt dans la bouche'  id='choice_4_48_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_8' id='label_4_48_8' class='gform-field-label gform-field-label--type-inline'>Mauvaise haleine ou mauvais go\u00fbt dans la bouche<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_48_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.9' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_48_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_48_9' id='label_4_48_9' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Souffrez-vous ou avez-vous souffert de l&#039;un des probl\u00e8mes suivants ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_49'><div class='gchoice gchoice_4_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Proth\u00e8ses dentaires'  id='choice_4_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_1' id='label_4_49_1' class='gform-field-label gform-field-label--type-inline'>Proth\u00e8ses dentaires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Orthodontie'  id='choice_4_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_2' id='label_4_49_2' class='gform-field-label gform-field-label--type-inline'>Orthodontie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Proth\u00e8ses dentaires partielles'  id='choice_4_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_3' id='label_4_49_3' class='gform-field-label gform-field-label--type-inline'>Proth\u00e8ses dentaires partielles<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Traitements parodontaux (gencives)'  id='choice_4_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_4' id='label_4_49_4' class='gform-field-label gform-field-label--type-inline'>Traitements parodontaux (gencives)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_49_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.5' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_49_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_49_5' id='label_4_49_5' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Si vous pouviez changer votre sourire, vous le feriez...<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_50'><div class='gchoice gchoice_4_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Rendre vos dents plus brillantes'  id='choice_4_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_1' id='label_4_50_1' class='gform-field-label gform-field-label--type-inline'>Rendre vos dents plus brillantes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Rendre vos dents plus droites'  id='choice_4_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_2' id='label_4_50_2' class='gform-field-label gform-field-label--type-inline'>Rendre vos dents plus droites<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Combler les \u00e9carts entre les dents'  id='choice_4_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_3' id='label_4_50_3' class='gform-field-label gform-field-label--type-inline'>Combler les \u00e9carts entre les dents<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Remplacer les obturations m\u00e9talliques par des obturations naturelles de la couleur des dents'  id='choice_4_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_4' id='label_4_50_4' class='gform-field-label gform-field-label--type-inline'>Remplacer les obturations m\u00e9talliques par des obturations naturelles de la couleur des dents<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.5' type='checkbox'  value='R\u00e9parer les dents \u00e9br\u00e9ch\u00e9es'  id='choice_4_50_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_5' id='label_4_50_5' class='gform-field-label gform-field-label--type-inline'>R\u00e9parer les dents \u00e9br\u00e9ch\u00e9es<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.6' type='checkbox'  value='Remplacer les dents manquantes'  id='choice_4_50_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_6' id='label_4_50_6' class='gform-field-label gform-field-label--type-inline'>Remplacer les dents manquantes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.7' type='checkbox'  value='Remplacer les vieilles couronnes qui ne sont pas assorties'  id='choice_4_50_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_7' id='label_4_50_7' class='gform-field-label gform-field-label--type-inline'>Remplacer les vieilles couronnes qui ne sont pas assorties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.8' type='checkbox'  value='Transformer le sourire'  id='choice_4_50_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_8' id='label_4_50_8' class='gform-field-label gform-field-label--type-inline'>Transformer le sourire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_50_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.9' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_50_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_50_9' id='label_4_50_9' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Quelle est l&#039;importance de votre sant\u00e9 dentaire pour vous?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_51'>\n\t\t\t<div class='gchoice gchoice_4_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='1'  id='choice_4_51_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_4_51\"   \/>\n\t\t\t\t\t<label for='choice_4_51_0' id='label_4_51_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='2'  id='choice_4_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_1' id='label_4_51_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='3'  id='choice_4_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_2' id='label_4_51_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='4'  id='choice_4_51_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_3' id='label_4_51_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='5'  id='choice_4_51_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_4' id='label_4_51_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='6'  id='choice_4_51_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_5' id='label_4_51_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='7'  id='choice_4_51_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_6' id='label_4_51_6' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='8'  id='choice_4_51_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_7' id='label_4_51_7' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='9'  id='choice_4_51_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_8' id='label_4_51_8' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_51_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='10'  id='choice_4_51_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_51_9' id='label_4_51_9' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_4_51'><small>Sur une \u00e9chelle de 1 \u00e0 10, 10 \u00e9tant la note la plus \u00e9lev\u00e9e<\/small><\/div><\/fieldset><fieldset id=\"field_4_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Comment \u00e9valueriez-vous votre sant\u00e9 dentaire actuelle ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_52'>\n\t\t\t<div class='gchoice gchoice_4_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='1'  id='choice_4_52_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_4_52\"   \/>\n\t\t\t\t\t<label for='choice_4_52_0' id='label_4_52_0' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='2'  id='choice_4_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_1' id='label_4_52_1' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='3'  id='choice_4_52_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_2' id='label_4_52_2' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='4'  id='choice_4_52_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_3' id='label_4_52_3' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='5'  id='choice_4_52_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_4' id='label_4_52_4' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='6'  id='choice_4_52_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_5' id='label_4_52_5' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='7'  id='choice_4_52_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_6' id='label_4_52_6' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='8'  id='choice_4_52_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_7' id='label_4_52_7' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='9'  id='choice_4_52_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_8' id='label_4_52_8' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_52_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='10'  id='choice_4_52_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_52_9' id='label_4_52_9' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_4_52'><small>Sur une \u00e9chelle de 1 \u00e0 10, 10 \u00e9tant la note la plus \u00e9lev\u00e9e<\/small><\/div><\/fieldset><div id=\"field_4_53\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_53'>Pourquoi quittez-vous votre ancien dentiste ?<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_4_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_54\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Dans le pass\u00e9, qu&#039;est-ce qui vous a emp\u00each\u00e9 d&#039;avoir des soins dentaires ?<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_55\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_55'>Quelle est la chose la plus importante concernant votre futur sourire et votre sant\u00e9 dentaire ?<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_4_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_56\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_56'>Quelle est la chose la plus importante pour vous concernant votre prochaine visite ?<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_4_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_57\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Ant\u00e9c\u00e9dents m\u00e9dicaux<\/h2><\/div><div id=\"field_4_58\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Les informations suivantes sont n\u00e9cessaires pour nous permettre de vous fournir les meilleurs soins dentaires possibles. Toutes les informations sont strictement priv\u00e9es et sont prot\u00e9g\u00e9es par la confidentialit\u00e9 m\u00e9decin-patient. Le dentiste examinera les questions et expliquera celles que vous ne comprenez pas. Veuillez remplir le formulaire en entier.<\/div><fieldset id=\"field_4_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00cates-vous actuellement trait\u00e9 pour une condition m\u00e9dicale ou avez-vous \u00e9t\u00e9 trait\u00e9 au cours de la derni\u00e8re ann\u00e9e ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_59'>\n\t\t\t<div class='gchoice gchoice_4_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Oui'  id='choice_4_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_59_0' id='label_4_59_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='Non'  id='choice_4_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_59_1' id='label_4_59_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_92\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_92'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_92' id='input_4_92' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Y a-t-il eu des changements dans votre \u00e9tat de sant\u00e9 g\u00e9n\u00e9ral au cours de la derni\u00e8re ann\u00e9e ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_60'>\n\t\t\t<div class='gchoice gchoice_4_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Oui'  id='choice_4_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_60_0' id='label_4_60_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Non'  id='choice_4_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_91\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_91'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_91' id='input_4_91' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Prenez-vous des m\u00e9dicaments, des m\u00e9dicaments sans ordonnance ou des suppl\u00e9ments \u00e0 base de plantes de toute sorte ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_61'>\n\t\t\t<div class='gchoice gchoice_4_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Oui'  id='choice_4_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_61_0' id='label_4_61_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non'  id='choice_4_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_61_1' id='label_4_61_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_90\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_90'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_90' id='input_4_90' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >As tu des allergies?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_62'>\n\t\t\t<div class='gchoice gchoice_4_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Oui'  id='choice_4_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_0' id='label_4_62_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Non'  id='choice_4_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_1' id='label_4_62_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_89\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_89'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_89' id='input_4_89' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 eu une r\u00e9action particuli\u00e8re ou ind\u00e9sirable \u00e0 des m\u00e9dicaments ou \u00e0 des injections ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_63'>\n\t\t\t<div class='gchoice gchoice_4_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Oui'  id='choice_4_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_63_0' id='label_4_63_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Non'  id='choice_4_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_63_1' id='label_4_63_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_88\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_88'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_4_88' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu de l&#039;asthme?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_64'>\n\t\t\t<div class='gchoice gchoice_4_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Oui'  id='choice_4_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_0' id='label_4_64_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Non'  id='choice_4_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_64_1' id='label_4_64_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu des probl\u00e8mes cardiaques ou de pression art\u00e9rielle ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_65'>\n\t\t\t<div class='gchoice gchoice_4_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Oui'  id='choice_4_65_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_65_0' id='label_4_65_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Non'  id='choice_4_65_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_65_1' id='label_4_65_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_96\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_96'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_96' id='input_4_96' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu un remplacement ou une r\u00e9paration d&#039;une valve cardiaque, une infection du c\u0153ur (c.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_66'>\n\t\t\t<div class='gchoice gchoice_4_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Oui'  id='choice_4_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_66_0' id='label_4_66_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Non'  id='choice_4_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_66_1' id='label_4_66_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_87\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_87' id='input_4_87' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous une articulation proth\u00e9tique ou artificielle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_67'>\n\t\t\t<div class='gchoice gchoice_4_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Oui'  id='choice_4_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_67_0' id='label_4_67_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Non'  id='choice_4_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_67_1' id='label_4_67_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_86\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_86'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_86' id='input_4_86' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous des conditions ou des traitements qui pourraient affecter votre syst\u00e8me immunitaire (par exemple, la leuc\u00e9mie, le SIDA, l&#039;infection par le VIH, la radioth\u00e9rapie, la chimioth\u00e9rapie) ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_68'>\n\t\t\t<div class='gchoice gchoice_4_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Oui'  id='choice_4_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_68_0' id='label_4_68_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Non'  id='choice_4_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_68_1' id='label_4_68_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_85\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_85'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_4_85' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_69\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 pour une maladie ou une op\u00e9ration ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_69'>\n\t\t\t<div class='gchoice gchoice_4_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Oui'  id='choice_4_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_69_0' id='label_4_69_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Non'  id='choice_4_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_69_1' id='label_4_69_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_84\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_84'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_84' id='input_4_84' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Avez-vous ou avez-vous d\u00e9j\u00e0 eu l&#039;un des probl\u00e8mes suivants ? Veuillez cocher tout ce qui s&#039;applique.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_72'><div class='gchoice gchoice_4_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='douleur thoracique, angine'  id='choice_4_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_1' id='label_4_72_1' class='gform-field-label gform-field-label--type-inline'>douleur thoracique, angine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='rhumatisme articulaire aigu'  id='choice_4_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_2' id='label_4_72_2' class='gform-field-label gform-field-label--type-inline'>rhumatisme articulaire aigu<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.3' type='checkbox'  value='stimulateur cardiaque'  id='choice_4_72_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_3' id='label_4_72_3' class='gform-field-label gform-field-label--type-inline'>stimulateur cardiaque<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.4' type='checkbox'  value='corticoth\u00e9rapie'  id='choice_4_72_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_4' id='label_4_72_4' class='gform-field-label gform-field-label--type-inline'>corticoth\u00e9rapie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.5' type='checkbox'  value='convulsions (\u00e9pilepsie)'  id='choice_4_72_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_5' id='label_4_72_5' class='gform-field-label gform-field-label--type-inline'>convulsions (\u00e9pilepsie)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.6' type='checkbox'  value='crise cardiaque'  id='choice_4_72_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_6' id='label_4_72_6' class='gform-field-label gform-field-label--type-inline'>crise cardiaque<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.7' type='checkbox'  value='prolapsus de la valve mitrale'  id='choice_4_72_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_7' id='label_4_72_7' class='gform-field-label gform-field-label--type-inline'>prolapsus de la valve mitrale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.8' type='checkbox'  value='les maladies pulmonaires'  id='choice_4_72_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_8' id='label_4_72_8' class='gform-field-label gform-field-label--type-inline'>les maladies pulmonaires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.9' type='checkbox'  value='diab\u00e8te'  id='choice_4_72_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_9' id='label_4_72_9' class='gform-field-label gform-field-label--type-inline'>diab\u00e8te<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.11' type='checkbox'  value='maladie du rein'  id='choice_4_72_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_11' id='label_4_72_11' class='gform-field-label gform-field-label--type-inline'>maladie du rein<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.12' type='checkbox'  value='accident vasculaire c\u00e9r\u00e9bral, AIT'  id='choice_4_72_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_12' id='label_4_72_12' class='gform-field-label gform-field-label--type-inline'>accident vasculaire c\u00e9r\u00e9bral, AIT<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.13' type='checkbox'  value='tuberculose'  id='choice_4_72_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_13' id='label_4_72_13' class='gform-field-label gform-field-label--type-inline'>tuberculose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.14' type='checkbox'  value='ulc\u00e8res d&#039;estomac'  id='choice_4_72_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_14' id='label_4_72_14' class='gform-field-label gform-field-label--type-inline'>ulc\u00e8res d'estomac<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.15' type='checkbox'  value='maladie thyro\u00efdienne'  id='choice_4_72_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_15' id='label_4_72_15' class='gform-field-label gform-field-label--type-inline'>maladie thyro\u00efdienne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.16' type='checkbox'  value='essoufflement'  id='choice_4_72_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_16' id='label_4_72_16' class='gform-field-label gform-field-label--type-inline'>essoufflement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.17' type='checkbox'  value='souffle au coeur'  id='choice_4_72_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_17' id='label_4_72_17' class='gform-field-label gform-field-label--type-inline'>souffle au coeur<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.18' type='checkbox'  value='cancer'  id='choice_4_72_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_18' id='label_4_72_18' class='gform-field-label gform-field-label--type-inline'>cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.19' type='checkbox'  value='arthrite'  id='choice_4_72_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_19' id='label_4_72_19' class='gform-field-label gform-field-label--type-inline'>arthrite<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.21' type='checkbox'  value='consommation de drogue\/alcool\/cannabis ou d\u00e9pendance'  id='choice_4_72_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_21' id='label_4_72_21' class='gform-field-label gform-field-label--type-inline'>consommation de drogue\/alcool\/cannabis ou d\u00e9pendance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.22' type='checkbox'  value='m\u00e9dicaments contre l&#039;ost\u00e9oporose (par exemple Fosamax, Actonel)'  id='choice_4_72_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_22' id='label_4_72_22' class='gform-field-label gform-field-label--type-inline'>m\u00e9dicaments contre l'ost\u00e9oporose (par exemple Fosamax, Actonel)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_72_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.23' type='checkbox'  value='Aucune de ces r\u00e9ponses'  id='choice_4_72_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_72_23' id='label_4_72_23' class='gform-field-label gform-field-label--type-inline'>Aucune de ces r\u00e9ponses<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Y a-t-il des conditions ou des maladies non \u00e9num\u00e9r\u00e9es ci-dessus que vous avez ou avez eues ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_73'>\n\t\t\t<div class='gchoice gchoice_4_73_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Oui'  id='choice_4_73_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_73_0' id='label_4_73_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_73_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_73' type='radio' value='Non'  id='choice_4_73_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_73_1' id='label_4_73_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_83\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_83'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_4_83' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Fumez-vous ou utilisez-vous d&#039;autres produits \u00e0 base de nicotine ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_74'>\n\t\t\t<div class='gchoice gchoice_4_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Oui'  id='choice_4_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_74_0' id='label_4_74_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Non'  id='choice_4_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_74_1' id='label_4_74_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Vous allaitez ou \u00eates enceinte ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_75'>\n\t\t\t<div class='gchoice gchoice_4_75_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Oui'  id='choice_4_75_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_75_0' id='label_4_75_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_75_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_75' type='radio' value='Non'  id='choice_4_75_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_75_1' id='label_4_75_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_100\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_100'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_4_100' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous un handicap ou \u00eates-vous une personne ayant une d\u00e9ficience visuelle<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_76'>\n\t\t\t<div class='gchoice gchoice_4_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Oui'  id='choice_4_76_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_76_0' id='label_4_76_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Non'  id='choice_4_76_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_76_1' id='label_4_76_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_82\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_82'>D\u00e9crivez s&#039;il vous plait:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_4_82' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_77\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Publication g\u00e9n\u00e9rale<\/h2><\/div><fieldset id=\"field_4_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >J&#039;accepte votre politique d&#039;annulation et je comprends qu&#039;un pr\u00e9avis de deux (2) jours ouvrables est requis pour reporter mon rendez-vous.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_78'>\n\t\t\t<div class='gchoice gchoice_4_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Je suis d&#039;accord'  id='choice_4_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_78_0' id='label_4_78_0' class='gform-field-label gform-field-label--type-inline'>Je suis d'accord<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Je ne suis pas d&#039;accord'  id='choice_4_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_78_1' id='label_4_78_1' class='gform-field-label gform-field-label--type-inline'>Je ne suis pas d'accord<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_93\" 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>Je, soussign\u00e9, certifie avoir fourni un historique personnel et m\u00e9dico-dentaire exact et complet et n'avoir sciemment omis aucune information. J'ai eu la chance de poser des questions et d'obtenir des r\u00e9ponses \u00e0 toute question concernant mes ant\u00e9c\u00e9dents m\u00e9dico-dentaires. J'autorise le dentiste \u00e0 effectuer les proc\u00e9dures de diagnostic n\u00e9cessaires pour d\u00e9terminer le traitement requis. Je comprends que les informations fournies par ou \u00e0 mon m\u00e9decin ou \u00e0 un autre professionnel de la sant\u00e9 peuvent \u00eatre n\u00e9cessaires, et je consens \u00e0 ce que ces informations soient fournies. Je comprends que la responsabilit\u00e9 du paiement des services dentaires pour moi-m\u00eame et les personnes \u00e0 ma charge est mienne, et j'assume la responsabilit\u00e9 des frais associ\u00e9s \u00e0 ces services. J'accepte que la relation entre moi-m\u00eame et le dentiste soit r\u00e9gie et interpr\u00e9t\u00e9e conform\u00e9ment aux lois de la province de l'Ontario.<\/p><\/div><div id=\"field_4_79\" 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_4_79'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_79' id='input_4_79_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_4_79_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_4_79' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/www.merbleuedental.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_4_79_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_4_79_resetbutton' 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style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_4_79_data' name='input_4_79_data' value=''><\/div><div class='gfield_description' id='gfield_description_4_79'><small>Utilisez votre souris ou votre doigt pour dessiner votre signature ci-dessus<\/small><\/div><\/div><div id=\"field_4_80\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_80'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_80' id='input_4_80' type='text' value='07\/28\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_80_date_format\" 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