{"id":16627,"date":"2018-10-10T13:11:23","date_gmt":"2018-10-10T17:11:23","guid":{"rendered":"http:\/\/woocommerce-242810-747202.cloudwaysapps.com?page_id=16627"},"modified":"2021-03-02T17:38:49","modified_gmt":"2021-03-02T22:38:49","slug":"questionnaire-medical","status":"publish","type":"page","link":"https:\/\/paroimplanto.ca\/questionnaire-medical","title":{"rendered":"Formulaire M\u00e9dical"},"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;\">QUESTIONNAIRE M\u00c9DICODENTAIRE S\u00c9CURIS\u00c9 ET CONFIDENTIEL<\/span><\/h1>\n<\/div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f16626-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=\"\/wp-json\/wp\/v2\/pages\/16627#wpcf7-f16626-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=\"16626\" \/>\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-f16626-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>Nom:<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>Pr\u00e9nom:<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>Sexe:<\/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>Adresse:<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>App:<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>Ville:<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>Code postal:<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>T\u00e9l Maison:<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>T\u00e9l Travail:<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 de naissance:<\/b>\n\t<\/p>\n<\/div>\n<div class=\"one-third\">\n\t<p><label>Jour:<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>Mois:<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>Ann\u00e9e:<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>Courriel:<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;\">Qui doit-on remercier pour vous avoir r\u00e9f\u00e9r\u00e9(e) \u00e0 notre cabinet ?<\/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>Autre:<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>Quelle est la raison de votre visite:<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. Etes-vous actuellement sous les soins d\u2019un m\u00e9decin ? ...<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"group1\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p>2. M\u00e9decin traitant:<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>T\u00e9l.:<\/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. Prenez-vous des m\u00e9dicaments ou en avez-vous pris au cours des 6 derniers mois ?<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-4\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label> Si oui, lesquels?<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>4. Prenez-vous des anovulants ? (pilules anticonceptionnelles)<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-5\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>Etes-vous enceinte ?<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-6\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><b style=\"text-decoration:underline;\">Avez-vous souffert ou souffrez-vous de <\/b>\n\t<\/p>\n\t<p><label>5. Troubles cardiaques (infarctus, angine, probl\u00e8mes valvulaires, souffle)<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-7\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>6. Fi\u00e8vre rhumatismale<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-8\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>7. Saignements prolong\u00e9s<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-9\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>8. An\u00e9mie<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-10\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>9. Tension art\u00e9rielle (pression)<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-11\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>Si oui<\/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=\"Haute\" \/><span class=\"wpcf7-list-item-label\">Haute<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"f-47[]\" value=\"Basse\" \/><span class=\"wpcf7-list-item-label\">Basse<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>10. Sinusite ou rhumes fr\u00e9quents<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-13\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>11. Tuberculose ou probl\u00e8mes pulmonaires<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-14\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>12. Troubles digestifs<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-15\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>13. Ost\u00e9oporose<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-16\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>14. Ulc\u00e8re d\u2019estomac<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-17\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>15. Probl\u00e8mes du foie (h\u00e9patite : A, B, C, cirrhose, 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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-18\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>16. Troubles du rein<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-19\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>17. Infection transmissibles sexuellement (I.T.S.)<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-20\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>18. Diab\u00e8te<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-21\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>19. Troubles thyro\u00efdiens<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-22\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>20. Maladies de la peau<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-23\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>21. Probl\u00e8mes oculaires (yeux)<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-24\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>22. Arthrite<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-25\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>23. \u00c9pilepsie<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-26\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>24. Trouble nerveux<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-27\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>25. Maux de t\u00eate fr\u00e9quents <\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-28\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>26. Etourdissements, \u00e9vanouissements<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-29\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>27. Maux d\u2019oreilles<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-30\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>28. Rhume des foins<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-311\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>29. Asthme<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-32\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>30. Fumez-vous?<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-33\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>31. Utilisez-vous la cigarette \u00e9lectronique?<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-331\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>32. Avez-vous d\u00e9j\u00e0 subi des traitements de radioth\u00e9rapie et\/ou chimioth\u00e9rapie (tumeur)?<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-34\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>33. Etes-vous atteint(e) du syndrome d\u2019immuno-d\u00e9ficience acquise (SIDA)?<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-36\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>34. Etes-vous s\u00e9ropositif au test du SIDA?<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-37\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>35. Avez-vous des proth\u00e8ses articulaires (hanches, genoux, 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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-38\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><b style=\"text-decoration:underline;\">36. Avez-vous d\u00e9j\u00e0 fait une r\u00e9action aux produits suivants?<\/b>\n\t<\/p>\n\t<div class=\"one-half\">\n\t\t<p><label>Aliments<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-39\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Aspirine<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-40\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>P\u00e9nicilline<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-41\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Autres antibiotiques<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-42\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Sp\u00e9cifiez: <\/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<\/div>\n\t<div class=\"one-half\">\n\t\t<p><label>Iode<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-43\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Sulfamid\u00e9s<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-44\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Cod\u00e9ine<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-45\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Anesth\u00e9sie locale<\/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=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"f-46\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t\t<p><label>Autres<\/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>Avez-vous des restrictions alimentaires (di\u00e8te, personnelles ou religieuses)?<br \/>\nSi oui, lesquels?<\/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>Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 hospitalis\u00e9 et\/ou subi des interventions chirurgicales autres que dentaires ?<br \/>\nSi oui, lesquelles et quand ?<\/label>\n\t<\/p>\n\t<p><label>Intervention: <\/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>Ann\u00e9e: <\/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>Intervention: <\/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>Ann\u00e9e: <\/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>Intervention: <\/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>Ann\u00e9e: <\/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>SVP nous fournir les informations concernant votre pharmacie<\/label>\n\t<\/p>\n<\/div>\n<div class=\"one-half\">\n\t<p><label>Nom:<\/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>Adresse:<\/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>Num\u00e9ro de t\u00e9l\u00e9phone:<\/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>Comment pourrions-nous rendre votre visite chez-nous aussi plaisante que 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>Quel est le nom de votre parodontiste ?<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=\"\">Aucun<\/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=\"Je, soussign\u00e9, d\u00e9clare avoir lu, compris, m\u2019\u00eatre renseign\u00e9 et avoir r\u00e9pondu au questionnaire m\u00e9dico-dentaire ci-dessus au meilleur de ma connaissance. Je m\u2019engage par la pr\u00e9sente, \u00e0 vous aviser de tout changement de mon \u00e9tat de sant\u00e9.\" \/><span class=\"wpcf7-list-item-label\">Je, soussign\u00e9, d\u00e9clare avoir lu, compris, m\u2019\u00eatre renseign\u00e9 et avoir r\u00e9pondu au questionnaire m\u00e9dico-dentaire ci-dessus au meilleur de ma connaissance. Je m\u2019engage par la pr\u00e9sente, \u00e0 vous aviser de tout changement de mon \u00e9tat de sant\u00e9.<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"one\">\n\t<p><label>Nom :<\/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=\"Envoyer\" \/>\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 - 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