{"id":33,"date":"2026-04-21T09:57:13","date_gmt":"2026-04-21T13:57:13","guid":{"rendered":"https:\/\/fabricegarnierorthodontiste.com\/formulaires\/?page_id=33"},"modified":"2026-04-29T10:07:30","modified_gmt":"2026-04-29T14:07:30","slug":"rendez-vous","status":"publish","type":"page","link":"https:\/\/fabricegarnierorthodontiste.com\/formulaires\/rendez-vous\/","title":{"rendered":"Rendez-vous"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-41\" src=\"https:\/\/fabricegarnierorthodontiste.com\/formulaires\/wp-content\/uploads\/2026\/04\/logo.png\" alt=\"\" width=\"144\" height=\"124\" \/><\/p>\n<h3><span style=\"color: #afc44b;\">Prendre rendez-vous<\/span><\/h3>\n<p><span style=\"color: #333333;\">Pour faire une demande de rendez-vous de consultation initiale, veuillez remplir le formulaire ci-dessous. Un membre du personnel se fera un plaisir de communiquer avec vous afin de vous attribuer une date et une plage horaire.<\/span><\/p>\n<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 gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_7' style='display:none'><style>#gform_wrapper_7[data-form-index=\"0\"].gform-theme,[data-parent-form=\"7_0\"]{--gf-color-primary: 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_7'  action='\/formulaires\/wp-json\/wp\/v2\/pages\/33' data-formid='7' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_7_9\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >AVIS IMPORTANT<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_9' tabindex='0'>Ce formulaire s\u2019adresse exclusivement aux nouveaux patients souhaitant une premi\u00e8re consultation en orthodontie. Veuillez noter que nous ne prenons pas en charge les appareils de r\u00e9tention (fil lingual ou coquille) lorsque le traitement initial n\u2019a pas \u00e9t\u00e9 r\u00e9alis\u00e9 dans notre clinique. Si vous avez \u00e9t\u00e9 trait\u00e9s \u00e0 notre clinique, nous vous invitons \u00e0 communiquer directement avec notre \u00e9quipe par t\u00e9l\u00e9phone au (450) 378-2365.<\/div><div class='ginput_container ginput_container_consent'><input name='input_9.1' id='input_7_9_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_9\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_9_1' >Je comprends<\/label><input type='hidden' name='input_9.2' value='Je comprends' class='gform_hidden' \/><input type='hidden' name='input_9.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_7_10\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >VEUILLEZ NOTER<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_10' tabindex='0'>Prenez note que nous ne sommes pas inscrits au R\u00e9gime canadien de soins dentaires.<\/div><div class='ginput_container ginput_container_consent'><input name='input_10.1' id='input_7_10_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_7_10\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_10_1' >Je comprends<\/label><input type='hidden' name='input_10.2' value='Je comprends' class='gform_hidden' \/><input type='hidden' name='input_10.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_7_11\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"background-color:#9cb03a;padding:20px;color:#ffffff;font-weight:bold;font-size:22px;\">Informations sur le (la) patient(e)<\/a><\/div><\/div><div id=\"field_7_1\" class=\"gfield gfield--type-text gfield--input-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_7_1'>Pr\u00e9nom et nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_7_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_12\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third 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_7_12'>Genre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_7_12' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Homme' >Homme<\/option><option value='Femme' >Femme<\/option><option value='Non binaire' >Non binaire<\/option><\/select><\/div><\/div><div id=\"field_7_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_7_14'>\u00c2ge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_7_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_16\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third 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_7_16'>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_16' id='input_7_16' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_16_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_16_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_16' class='gform_hidden' value='https:\/\/fabricegarnierorthodontiste.com\/formulaires\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_7_13\" class=\"gfield gfield--type-select gfield--input-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_7_13'>Langue<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_7_13' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Fran\u00e7ais' >Fran\u00e7ais<\/option><option value='Anglais' >Anglais<\/option><\/select><\/div><\/div><fieldset id=\"field_7_15\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full 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' >Adresse compl\u00e8te<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_7_15_1' value=''    aria-required='true'    \/>\n                                        <label for='input_7_15_1' id='input_7_15_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_15_2_container' >\n                                        <input type='text' name='input_15.2' id='input_7_15_2' value=''     aria-required='false'   \/>\n                                        <label for='input_7_15_2' id='input_7_15_2_label' class='gform-field-label gform-field-label--type-sub '>Appartement<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_7_15_3' value=''    aria-required='true'    \/>\n                                    <label for='input_7_15_3' id='input_7_15_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_15_4_container' >\n                                        <select name='input_15.4' id='input_7_15_4'     aria-required='true'    ><option value='' ><\/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' selected='selected'>Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_7_15_4' id='input_7_15_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_7_15_5' value=''    aria-required='true'    \/>\n                                    <label for='input_7_15_5' id='input_7_15_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_7_15_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_7_3\" class=\"gfield gfield--type-email gfield--input-type-email 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_7_3'>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_3' id='input_7_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_7_4\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_7_4'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_7_4' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_7_17'>Pr\u00e9nom et nom du premier parent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_7_17' type='text' value='' class='large'  aria-describedby=\"gfield_description_7_17\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_17'>(Si le patient a moins de 18 ans)<\/div><\/div><div id=\"field_7_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_18'>Pr\u00e9nom et nom du deuxi\u00e8me parent<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_7_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_7_18\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_7_18'>(Si le patient a moins de 18 ans)<\/div><\/div><div id=\"field_7_19\" class=\"gfield gfield--type-text gfield--input-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_7_19'>Nom de la personne \u00e0 contacter pour la prise de rendez-vous<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_7_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_20\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_7_20'>T\u00e9l\u00e9phone de la personne \u00e0 contacter<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_7_20' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Pr\u00e9f\u00e9rez-vous recevoir les confirmations de rendez-vous par :<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_21'>\n\t\t\t<div class='gchoice gchoice_7_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Courriel'  id='choice_7_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_21_0' id='label_7_21_0' class='gform-field-label gform-field-label--type-inline'>Courriel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_7_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Message texte'  id='choice_7_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_21_1' id='label_7_21_1' class='gform-field-label gform-field-label--type-inline'>Message texte<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_22\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_7_22'>Pr\u00e9cisez le num\u00e9ro de t\u00e9l\u00e9phone pour le message texte :<\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_7_22' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 un dossier \u00e0 notre clinique avec un autre membre de votre famille?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_7_23'>\n\t\t\t<div class='gchoice gchoice_7_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Oui'  id='choice_7_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_0' id='label_7_23_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_7_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Non'  id='choice_7_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_23_1' id='label_7_23_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_24\" class=\"gfield gfield--type-text gfield--input-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_7_24'>Si oui, indiquez le nom du patient :<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_7_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_25\" class=\"gfield gfield--type-html gfield--input-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\"  ><div style=\"background-color:#9cb03a;padding:20px;color:#ffffff;font-weight:bold;font-size:22px;\">Informations sp\u00e9cifiques<\/a><\/div><\/div><div id=\"field_7_26\" class=\"gfield gfield--type-text gfield--input-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_7_26'>Pr\u00e9nom et nom de votre dentiste<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_7_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_7_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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' >Raison(s) du rendez-vous<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_7_40'><div class='gchoice gchoice_7_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Manque d&#039;espace'  id='choice_7_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_1' id='label_7_40_1' class='gform-field-label gform-field-label--type-inline'>Manque d'espace<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Chevauchement'  id='choice_7_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_2' id='label_7_40_2' class='gform-field-label gform-field-label--type-inline'>Chevauchement<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Traitement n\u00e9cessitant une chirurgie des m\u00e2choires'  id='choice_7_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_3' id='label_7_40_3' class='gform-field-label gform-field-label--type-inline'>Traitement n\u00e9cessitant une chirurgie des m\u00e2choires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Canine incluse'  id='choice_7_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_4' id='label_7_40_4' class='gform-field-label gform-field-label--type-inline'>Canine incluse<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.5' type='checkbox'  value='Esth\u00e9tique'  id='choice_7_40_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_5' id='label_7_40_5' class='gform-field-label gform-field-label--type-inline'>Esth\u00e9tique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_40_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.6' type='checkbox'  value='Autre'  id='choice_7_40_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_40_6' id='label_7_40_6' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_28\" class=\"gfield gfield--type-textarea gfield--input-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_7_28'>Informations additionnelles<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_7_28' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_7_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full 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 re\u00e7u un traitement d&#039;orthodontie?<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_7_29'>\n\t\t\t<div class='gchoice gchoice_7_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Oui'  id='choice_7_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_0' id='label_7_29_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_7_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Non'  id='choice_7_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_7_29_1' id='label_7_29_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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 oui, quel traitement d&#039;orthodontie avez-vous d\u00e9j\u00e0 re\u00e7u?<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_7_30'><div class='gchoice gchoice_7_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Broches'  id='choice_7_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_30_1' id='label_7_30_1' class='gform-field-label gform-field-label--type-inline'>Broches<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Coquilles Invisalign'  id='choice_7_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_30_2' id='label_7_30_2' class='gform-field-label gform-field-label--type-inline'>Coquilles Invisalign<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Appareil d\u2019expansion'  id='choice_7_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_30_3' id='label_7_30_3' class='gform-field-label gform-field-label--type-inline'>Appareil d\u2019expansion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Autre'  id='choice_7_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_30_4' id='label_7_30_4' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_7_31\" class=\"gfield gfield--type-text gfield--input-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_7_31'>Si Autre, pr\u00e9cisez :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_7_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_7_32\" class=\"gfield gfield--type-select gfield--input-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_7_32'>\u00cates-vous actuellement en traitement avec des appareils en bouche (broches, appareils d&#039;expansion, goutti\u00e8res d&#039;alignement (Invisalign)...)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_7_32' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><div id=\"field_7_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_7_39'>Informations additionnelles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_7_39' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_7_33\" class=\"gfield gfield--type-select gfield--input-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_7_33'>Est-ce que le patient habitera la r\u00e9gion de Granby durant les 2 prochaines ann\u00e9es (d\u00e9m\u00e9nagement pr\u00e9vu pour les \u00e9tudes ou le travail, voyage pr\u00e9vu de plus de 6 mois...)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_7_33' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><fieldset id=\"field_7_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full 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' >De quelle(s) fa\u00e7on(s) avez-vous entendu parler de la clinique?<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_7_34'><div class='gchoice gchoice_7_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Dentiste'  id='choice_7_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_34_1' id='label_7_34_1' class='gform-field-label gform-field-label--type-inline'>Dentiste<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Recherche internet'  id='choice_7_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_34_2' id='label_7_34_2' class='gform-field-label gform-field-label--type-inline'>Recherche internet<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='Affiche de la clinique'  id='choice_7_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_34_3' id='label_7_34_3' class='gform-field-label gform-field-label--type-inline'>Affiche de la clinique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='Amis\/famille'  id='choice_7_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_34_4' id='label_7_34_4' class='gform-field-label gform-field-label--type-inline'>Amis\/famille<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_7_34_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.5' type='checkbox'  value='Autre'  id='choice_7_34_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_7_34_5' id='label_7_34_5' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_7_36\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Exactitude des renseignements<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_7_36' tabindex='0'>Je certifie que les renseignements fournis sont exacts. 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