{"id":16640,"date":"2018-10-11T18:08:06","date_gmt":"2018-10-11T22:08:06","guid":{"rendered":"http:\/\/woocommerce-242810-747202.cloudwaysapps.com?page_id=16640"},"modified":"2021-03-02T17:36:14","modified_gmt":"2021-03-02T22:36:14","slug":"medical-questionnaire","status":"publish","type":"page","link":"https:\/\/paroimplanto.ca\/en\/medical-questionnaire","title":{"rendered":"Medical Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container hundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-overflow:visible;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><h1 style=\"text-align: left;\"><span style=\"color: #9d1c30;\">SECURED AND CONFIDENTIAL MEDICAL QUESTIONNAIRE<\/span><\/h1>\n<\/div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f16648-o1\" lang=\"fr-FR\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/16640#wpcf7-f16648-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"16648\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f16648-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<link rel=\"stylesheet\" href=\"https:\/\/paroimplanto.ca\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/css\/frontend.css\" \/><script type=\"text\/javascript\" src=\"https:\/\/paroimplanto.ca\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/js\/frontend.js?ver=2.1.10\"><\/script><div class=\"one-third\">\n\t<p><label>Last Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom\" \/><\/span> <\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>First Name:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"prenom\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"prenom\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Gender:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"sx\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"sx\" value=\"M\" \/><span class=\"wpcf7-list-item-label\">M<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"sx\" value=\"F\" \/><span class=\"wpcf7-list-item-label\">F<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Address:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adresse-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adresse-1\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Apt:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"app\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>City:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ville\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ville\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Postal Code:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adresse-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adresse-2\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Tel Home:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-maison\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tel-maison\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Cell:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cell\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cell\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Tel Work:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel-travail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tel-travail\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one\">\n\t<p><b style=\"text-decoration:underline;\">Date of Birth:<\/b>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Day:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-de-naissance-jour\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"date-de-naissance-jour\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Month:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mois\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mois\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Year:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"annee\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"annee\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Email:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"courriel\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"courriel\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one\">\n\t<p><b style=\"text-decoration:underline;\">Who should we thank for referring you to our office ?<\/b>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Dr:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"qui-doiton-remercier-pour-vous-avoir-referee-a-notre-cabinet-dr\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"qui-doiton-remercier-pour-vous-avoir-referee-a-notre-cabinet-dr\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Other:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"autre\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"autre\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<div class=\"one\">\n\t<p><label>What is the main reason for your visit?:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"quelle-est-la-raison-de-votre-visite\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"quelle-est-la-raison-de-votre-visite\" \/><\/span><\/label>\n\t<\/p>\n<\/div>\n<hr \/>\n<div class=\"one-half\">\n\t<p><label>1. Are you presently under a doctor's care?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"group1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"group1\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"group1\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p>2. Attending physician:<br \/>\n<label>Dr:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medecin-traitant-dr\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"medecin-traitant-dr\" \/><\/span>\n\t<\/p>\n\t<p><label>Tel.:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tel\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tel\" \/><\/span>\n\t<\/p>\n\t<p><label>3. Are you presently taking any drugs or medication, or have you taken any in the last 6 months?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-4\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-4\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-4\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>If so, which ones?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-6-derniers-mois-si-oui-lesquels-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"f-6-derniers-mois-si-oui-lesquels-2\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>Are you taking any birth control pill ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-5\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-5\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-5\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>Are you pregnant?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-6\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-6\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-6\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><b style=\"text-decoration:underline;\">Are you suffering or have you ever suffered from?<\/b>\n\t<\/p>\n\t<p><label>5. Heart disease (stroke, angina, valvular problems, murmur)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-7\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-7\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-7\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>6. Rheumatic fever<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-8\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-8\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-8\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>7. Prolonged bleeding<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-9\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-9\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-9\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>8. Anemia<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-10\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-10\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-10\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>9. Blood pressure<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-11\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-11\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-11\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>If so<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-47\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"f-47[]\" value=\"High\" \/><span class=\"wpcf7-list-item-label\">High<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"f-47[]\" value=\"Low\" \/><span class=\"wpcf7-list-item-label\">Low<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>10. Frequent colds or sinusitis<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-13\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-13\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-13\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>11. Tuberculosis or lung problems<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-14\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-14\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-14\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>12. Digestive problems<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-15\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-15\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-15\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>13. Stomach ulcer<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-16\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-16\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-16\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>14. Osteoporosis<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-17\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-17\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-17\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>15. Liver disease (hepatitis : A, B, C, cirrhosis, etc.)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-18\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-18\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-18\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>16. Kidney disease<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-19\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-19\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-19\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>17. Sexually transmitted infections (S.T.I.)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-20\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-20\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-20\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>18. Diabetes<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-21\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-21\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-21\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>19. Thyroid problems<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-22\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-22\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-22\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>20. Skin disease<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-23\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-23\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-23\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>21. Eye problems<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-24\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-24\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-24\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>22. Arthritis<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-25\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-25\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-25\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>23. Epilepsy<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-26\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-26\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-26\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>24. Nervous disorders<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-27\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-27\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-27\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>25. Frequent headaches<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-28\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-28\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-28\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>26. Dizzy spells and fainting spells<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-29\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-29\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-29\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>27. Earaches<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-30\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-30\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-30\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>28. Hay fever<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-311\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-311\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-311\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>29. Asthma<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-32\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-32\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-32\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>30. Do you smoke?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-33\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-33\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-33\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>31. Are you using the electronic cigarette?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-331\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-331\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-331\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>32. Have you ever had radiotherapy and\/or chemotherapy (cancer)?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-34\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-34\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-34\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>33. Are you an HIV carrier?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-36\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-36\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-36\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>34. Do you have AIDS?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-37\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-37\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-37\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>35. Do you have artificial joints (knee, hip, etc.)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-38\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-38\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-38\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><b style=\"text-decoration:underline;\">36. Do you have any of the following allergies?<\/b>\n\t<\/p>\n\t<div class=\"one-half\">\n\t\t<p><label>Food<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-39\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-39\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-39\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Penicillin<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-40\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-40\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-40\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Other antibiotics<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-41\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-41\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-41\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Specify: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"specifiez\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"specifiez\" \/><\/span>\n\t\t<\/p>\n\t\t<p><label>Aspirin<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-42\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-42\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-42\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"one-half\">\n\t\t<p><label>Iodine<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-43\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-43\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-43\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Sulfonamide<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-44\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-44\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-44\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Codeine<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-45\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-45\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-45\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Local anasthesia<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"f-46\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"f-46\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-46\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Others<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"autres\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"autres\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<hr style=\"clear:both;\" \/>\n<div class=\"one-half\">\n\t<p><label>Do you have any dietary restrictions (special diet, personal or religious)?<br \/>\nIf so, which ones?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"si-oui-lesquels\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"si-oui-lesquels\" \/><\/span>\n\t<\/p>\n\t<p><label>Were you ever hospitalized or have you undergone surgery other than dental? If so, indicate which ones and when?<\/label>\n\t<\/p>\n\t<p><label>Surgery: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"si-oui-lesquelles-et-quand-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"si-oui-lesquelles-et-quand-1\" \/><\/span>\n\t<\/p>\n\t<p><label>Year: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"annee_2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"annee_2\" \/><\/span>\n\t<\/p>\n<hr \/>\n\t<p><label>Surgery: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"si-oui-lesquelles-et-quand-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"si-oui-lesquelles-et-quand-2\" \/><\/span>\n\t<\/p>\n\t<p><label>Year: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"annee_3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"annee_3\" \/><\/span>\n\t<\/p>\n<hr \/>\n\t<p><label>Surgery: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"si-oui-lesquelles-et-quand-3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"si-oui-lesquelles-et-quand-3\" \/><\/span>\n\t<\/p>\n\t<p><label>Year: <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"annee_4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"annee_4\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Please provide the information about your pharmacy.<\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Name:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom_pharmacie\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom_pharmacie\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Address:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"adresse_pharmacie\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"adresse_pharmacie\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Phone number:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telephone_pharmacie\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"telephone_pharmacie\" \/><\/span>\n\t<\/p>\n<\/div>\n<hr style=\"clear:both;\" \/>\n<div class=\"one\">\n\t<p><label>What could we do to make your visit in our office as pleasant as possible?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"comment-pourrionsnous-rendre-votre-visite-cheznous-aussi-plaisante-que-possible-2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"comment-pourrionsnous-rendre-votre-visite-cheznous-aussi-plaisante-que-possible-2\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one\">\n\t<p><label>Who is your periodontist ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"votre-dentiste\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"votre-dentiste\"><option value=\"\">None<\/option><option value=\"Dr. Drouin\">Dr. Drouin<\/option><option value=\"Dr. Tach\u00e9\">Dr. Tach\u00e9<\/option><option value=\"Dr. Shenouda\">Dr. Shenouda<\/option><\/select><\/span><\/label>\n\t<\/p>\n<\/div>\n<hr style=\"clear:both;\" \/>\n<div class=\"one\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"soussigne\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"soussigne[]\" value=\"I, the undersigned, hereby declare that I have read, understood and answered the above medical questionnaire to the best of my\nknowledge. I also hereby promise to inform you of any change to my health.\" \/><span class=\"wpcf7-list-item-label\">I, the undersigned, hereby declare that I have read, understood and answered the above medical questionnaire to the best of my\nknowledge. I also hereby promise to inform you of any change to my health.<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one\">\n\t<p><label>Name:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom_soussigne\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom_soussigne\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one\">\n\t<p><label>Date:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date_soussigne\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"date_soussigne\" \/><\/span>\n\t<\/p>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Send\" \/>\n<\/p><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-size:1px;--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n<\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Medical Form - PARO IMPLANTO Pointe-Claire<\/title>\n<meta name=\"robots\" content=\"noindex, follow\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Medical Form - PARO IMPLANTO Pointe-Claire\" \/>\n<meta property=\"og:url\" content=\"https:\/\/paroimplanto.ca\/en\/medical-questionnaire\" \/>\n<meta property=\"og:site_name\" content=\"PARO IMPLANTO Pointe-Claire\" \/>\n<meta property=\"article:modified_time\" content=\"2021-03-02T22:36:14+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/paroimplanto.ca\/en\/medical-questionnaire\",\"url\":\"https:\/\/paroimplanto.ca\/en\/medical-questionnaire\",\"name\":\"Medical Form - 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