{"id":14187,"date":"2024-02-16T11:06:15","date_gmt":"2024-02-16T11:06:15","guid":{"rendered":"https:\/\/argyleassociates.com\/?page_id=14187"},"modified":"2024-03-11T12:41:05","modified_gmt":"2024-03-11T12:41:05","slug":"formulaire-de-reference-2","status":"publish","type":"page","link":"https:\/\/argyleassociates.com\/fr\/pour-les-medecins-referents\/formulaire-de-reference-2\/","title":{"rendered":"Formulaire de r\u00e9f\u00e9rence"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"14187\" class=\"elementor elementor-14187\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-207d237e elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"207d237e\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-9bc0c80\" data-id=\"9bc0c80\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4575a8c5 elementor-widget elementor-widget-rt-banner\" data-id=\"4575a8c5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"rt-banner.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"main-banner-wrap2 motion-effects-wrap\">\r\n\t\t<div class=\"shape-list\">\r\n\t  <ul>\r\n\t   \t  \t\t<li><\/li>\r\n\t  \t\t  <\/ul>\r\n\t<\/div>\r\n\t\t  <div class=\"row align-items-center\">\r\n\t    <div class=\"col-lg-6\">\r\n\t      <div class=\"main-banner-box1 main-banner-box4\">\r\n\t      \t\t        <div class=\"heading-title\">\r\n\t          <h1>Formulaire de r\u00e9f\u00e9rence<\/h1>\r\n\t        <\/div>\r\n\t        \t        \t        <div class=\"item-button\">\r\n\t          <a class=\"item-btn\" href=\"https:\/\/argyleassociates.com\/fr\/contactez-nous\/\">Contactez-nous<i class=\"fas fa-angle-right\"><\/i><\/a>\t        <\/div>\r\n\t        \t      <\/div>\r\n\t    <\/div>\r\n\t    <div class=\"col-lg-6\">\r\n\t      <div class=\"main-banner-box2 main-banner-box3 wow fadeInRight\" data-wow-delay=\".6s\">\r\n\t        <div class=\"item-img\">\r\n\t          \t        \t<img fetchpriority=\"high\" decoding=\"async\" width=\"1000\" height=\"600\" src=\"https:\/\/argyleassociates.com\/wp-content\/uploads\/2023\/08\/referral-form.jpg\" class=\"attachment-full size-full\" alt=\"Referral\" srcset=\"https:\/\/argyleassociates.com\/wp-content\/uploads\/2023\/08\/referral-form.jpg 1000w, https:\/\/argyleassociates.com\/wp-content\/uploads\/2023\/08\/referral-form-300x180.jpg 300w\" sizes=\"(max-width: 1000px) 100vw, 1000px\" \/>\t          \t          \t        <\/div>\r\n\t      <\/div>\r\n\t    <\/div>\r\n\t  <\/div>\r\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-7400052 elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7400052\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-be95334\" data-id=\"be95334\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c5efbbe elementor-widget__width-inherit elementor-widget elementor-widget-rt-text-with-title\" data-id=\"c5efbbe\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"rt-text-with-title.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\r\n<div class=\"rt-el-twt-5\">\t\r\n\t<div class=\"item-content\">\r\n\t\t\t\t\t\t\t\t<p><span class=\"Y2IQFc\" lang=\"fr\">C'est un honneur de faire partie de votre \u00e9quipe de soins de sant\u00e9<\/span>. <span class=\"Y2IQFc\" lang=\"fr\">Merci de nous avoir confi\u00e9 vos patients.<\/span><\/p><div id=\"tw-target-text-container\" class=\"tw-ta-container F0azHf tw-nfl\"><p id=\"tw-target-text\" class=\"tw-data-text tw-text-large tw-ta\" dir=\"ltr\" data-placeholder=\"Translation\"><span class=\"Y2IQFc\" lang=\"fr\">\u00a0 \u00a0 Vous pouvez r\u00e9f\u00e9rer des patients en remplissant et en soumettant ce formulaire de recommandation en ligne s\u00e9curis\u00e9 ou <a href=\"https:\/\/argyleassociates.com\/wp-content\/uploads\/2023\/08\/argyle_referral-form-2021.pdf\" target=\"_blank\" rel=\"noopener\">en imprimant un formulaire vierge<\/a> et en nous le retournant.<\/span><\/p><\/div><div class=\"iYB33c\"><div id=\"tw-tmenu\" class=\"tw-menu\">\u00a0<\/div><\/div>\t\r\n\t\t\t<\/div>\r\n<\/div>\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e41848d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e41848d\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-34339af\" data-id=\"34339af\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0b5faf6 elementor-widget elementor-widget-shortcode\" data-id=\"0b5faf6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_16'  action='\/fr\/wp-json\/wp\/v2\/pages\/14187' data-formid='16' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_16_66\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_66'>Facebook<\/label><div class='ginput_container'><input name='input_66' id='input_16_66' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_16_66'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><div id=\"field_16_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information du Patient<\/h3><\/div><div id=\"field_16_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter 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_16_40'>Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_16_40' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter 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_16_41'>Nom de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_16_41' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter 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_16_3'>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_3' id='input_16_3' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='jj-mm-aaaa' aria-describedby=\"input_16_3_date_format gfield_description_16_3\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_16_3_date_format' class='screen-reader-text'>JJ - MM - AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_3' class='gform_hidden' value='https:\/\/argyleassociates.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_16_3'>(dd-mm-yyyy)<\/div><\/div><div id=\"field_16_39\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-quarter 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_16_39'>Date de soumission :<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_39' id='input_16_39' type='text' value='05-02-2026' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='jj-mm-aaaa' aria-describedby=\"input_16_39_date_format gfield_description_16_39\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_16_39_date_format' class='screen-reader-text'>JJ - MM - AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_39' class='gform_hidden' value='https:\/\/argyleassociates.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_16_39'>(dd-mm-yyyy)<\/div><\/div><div id=\"field_16_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_12'>Adresse :<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_16_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_13'>Villle :<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_16_13' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_14'>Province :<\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_16_14' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Ontario' >Ontario<\/option><option value='Quebec' >Quebec<\/option><\/select><\/div><\/div><div id=\"field_16_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_15'>Code postale :<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_16_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_5\" class=\"gfield gfield--type-phone gfield--input-type-phone 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_16_5'>T\u00e9l\u00e9phone domicile :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_16_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_38\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_38'>T\u00e9l\u00e9phone mobile :<\/label><div class='ginput_container ginput_container_phone'><input name='input_38' id='input_16_38' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_16\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_16'>Adresse courriel :<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_16' id='input_16_16' type='email' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_16_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">D\u00e9tails de la r\u00e9f\u00e9rence<\/h3><\/div><fieldset id=\"field_16_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col 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' >Chirurgien demand\u00e9 :<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_30'><div class='gchoice gchoice_16_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Premier disponible'  id='choice_16_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_1' id='label_16_30_1' class='gform-field-label gform-field-label--type-inline'>Premier disponible<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Dr Ian Buckley'  id='choice_16_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_2' id='label_16_30_2' class='gform-field-label gform-field-label--type-inline'>Dr Ian Buckley<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Dr Hassan G. Moghadam'  id='choice_16_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_3' id='label_16_30_3' class='gform-field-label gform-field-label--type-inline'>Dr Hassan G. Moghadam<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='Dr Kevin J. Butterfield'  id='choice_16_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_4' id='label_16_30_4' class='gform-field-label gform-field-label--type-inline'>Dr Kevin J. Butterfield<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='Dr Taylor P. McGuire'  id='choice_16_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_5' id='label_16_30_5' class='gform-field-label gform-field-label--type-inline'>Dr Taylor P. McGuire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.6' type='checkbox'  value='Dr Adam M. Irvine'  id='choice_16_30_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_6' id='label_16_30_6' class='gform-field-label gform-field-label--type-inline'>Dr Adam M. Irvine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.7' type='checkbox'  value='Dr Andrew Wing Cheong Lee'  id='choice_16_30_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_7' id='label_16_30_7' class='gform-field-label gform-field-label--type-inline'>Dr Andrew Wing Cheong Lee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.8' type='checkbox'  value='Dr. John E. Guenther'  id='choice_16_30_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_8' id='label_16_30_8' class='gform-field-label gform-field-label--type-inline'>Dr. John E. Guenther<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_30_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.9' type='checkbox'  value='Dr. Harshdeep S. Mangat'  id='choice_16_30_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_30_9' id='label_16_30_9' class='gform-field-label gform-field-label--type-inline'>Dr. Harshdeep S. Mangat<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_27\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_27'>S\u00e9lectionnez l&#039;emplacement\t:<\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_16_27' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Barrhaven' >Barrhaven<\/option><option value='Carling &amp; Surgicentre West' >Carling &amp; Surgicentre West<\/option><option value='Orleans &amp; Surgicentre East' >Orleans &amp; Surgicentre East<\/option><option value='Kanata' >Kanata<\/option><\/select><\/div><\/div><div id=\"field_16_7\" 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_16_7'>Dentiste r\u00e9f\u00e9rant :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_16_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_20\" class=\"gfield gfield--type-email gfield--input-type-email 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_16_20'>Adresse courriel du dentiste :<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_20' id='input_16_20' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_16_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Avez-vous des radiographies ou autres documents \u00e0 t\u00e9l\u00e9charger?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_9'>\n\t\t\t<div class='gchoice gchoice_16_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Oui'  id='choice_16_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_9_0' id='label_16_9_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_16_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Non'  id='choice_16_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_9_1' id='label_16_9_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_9_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Donn\u00e9 au patient'  id='choice_16_9_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_9_2' id='label_16_9_2' class='gform-field-label gform-field-label--type-inline'>Donn\u00e9 au patient<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_17\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_16_17'>T\u00e9l\u00e9chargement de documents :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_16_17'>(T\u00e9l\u00e9chargez jusqu'\u00e0 5 fichiers, images et\/ou documents, avec une taille de fichier maximale de 12 Mb par fichier.)<\/div><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_16_17' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_16_17&quot;,&quot;container&quot;:&quot;gform_multifile_upload_16_17&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_16_17&quot;,&quot;filelist&quot;:&quot;gform_preview_16_17&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/argyleassociates.com\\\/fr\\\/?gf_page=6c451cb44045f38&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/argyleassociates.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/argyleassociates.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;12582912b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:16,&quot;field_id&quot;:17,&quot;_gform_file_upload_nonce_16_17&quot;:&quot;6ec7e3096e&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_16_17&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_16_17' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_16_17' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_16_17 gfield_description_16_17\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_16_17'>Taille max. des fichiers\u00a0: 12 MB, Max. des fichiers\u00a0: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_16_17'><\/ul> <div id='gform_preview_16_17' class='ginput_preview_list'><\/div><\/div><\/div><fieldset id=\"field_16_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><legend class='gfield_label gform-field-label' >Le patient a-t-il une assurance ?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_43'>\n\t\t\t<div class='gchoice gchoice_16_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Oui'  id='choice_16_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_43_0' id='label_16_43_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_16_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Non'  id='choice_16_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_43_1' id='label_16_43_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_44\" 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\"  ><h3>INFORMATIONS PRINCIPALES SUR LA R\u00c8GLEMENT<\/h3><\/div><div id=\"field_16_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_45'>Pr\u00e9nom du titulaire de la police<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_16_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_46'>Nom du titulaire de la police<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_16_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sexe du titulaire de la police (tel qu&#039;enregistr\u00e9 aupr\u00e8s du r\u00e9gime de soins dentaires)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_47'>\n\t\t\t<div class='gchoice gchoice_16_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Homme'  id='choice_16_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_47_0' id='label_16_47_0' class='gform-field-label gform-field-label--type-inline'>Homme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Femme'  id='choice_16_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_47_1' id='label_16_47_1' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_48\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_48'>Date de naissance du titulaire de la police<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_48' id='input_16_48' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_16_48_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_16_48_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_48' class='gform_hidden' value='https:\/\/argyleassociates.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_16_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Relation du preneur d&#039;assurance avec le patient<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_49'>\n\t\t\t<div class='gchoice gchoice_16_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Soi'  id='choice_16_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_49_0' id='label_16_49_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Parent'  id='choice_16_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_49_1' id='label_16_49_1' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_49_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Conjoint'  id='choice_16_49_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_49_2' id='label_16_49_2' class='gform-field-label gform-field-label--type-inline'>Conjoint<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_49_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Loi commune'  id='choice_16_49_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_49_3' id='label_16_49_3' class='gform-field-label gform-field-label--type-inline'>Loi commune<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_50'>Nom de la compagnie d\u2019assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_16_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_51'>Groupe\/Plan\/Contrat<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_16_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_52'>Membre\/Certificat\/ID<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_16_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Le patient est-il un \u00e9tudiant de 21 ans ou plus\u00a0?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_53'>\n\t\t\t<div class='gchoice gchoice_16_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Oui'  id='choice_16_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_53_0' id='label_16_53_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_16_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='Non'  id='choice_16_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_53_1' id='label_16_53_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_54'>Nom de l&#039;\u00e9cole<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_16_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_55\" 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\"  ><h3>INFORMATIONS SECONDAIRES SUR LA POLITIQUE<\/h3><\/div><div id=\"field_16_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_56'>Pr\u00e9nom du titulaire de la police<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_16_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_57'>Nom du titulaire de la police<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_16_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sexe du titulaire de la police (tel qu&#039;enregistr\u00e9 aupr\u00e8s du r\u00e9gime de soins dentaires)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_58'>\n\t\t\t<div class='gchoice gchoice_16_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Homme'  id='choice_16_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_58_0' id='label_16_58_0' class='gform-field-label gform-field-label--type-inline'>Homme<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='Femme'  id='choice_16_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_58_1' id='label_16_58_1' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_59\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_59'>Date de naissance du titulaire de la police<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_59' id='input_16_59' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_16_59_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_16_59_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_59' class='gform_hidden' value='https:\/\/argyleassociates.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_16_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Relation du preneur d&#039;assurance avec le patient<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_60'>\n\t\t\t<div class='gchoice gchoice_16_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Soi'  id='choice_16_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_60_0' id='label_16_60_0' class='gform-field-label gform-field-label--type-inline'>Soi<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Parent'  id='choice_16_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_60_1' id='label_16_60_1' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Conjoint'  id='choice_16_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_60_2' id='label_16_60_2' class='gform-field-label gform-field-label--type-inline'>Conjoint<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Loi commune'  id='choice_16_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_60_3' id='label_16_60_3' class='gform-field-label gform-field-label--type-inline'>Loi commune<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_61'>Nom de la compagnie d\u2019assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_16_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_62'>Groupe\/Plan\/Contrat<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_16_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_63'>Membre\/Certificat\/ID<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_16_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_16_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Le patient est-il un \u00e9tudiant de 21 ans ou plus\u00a0?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_16_64'>\n\t\t\t<div class='gchoice gchoice_16_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Oui'  id='choice_16_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_64_0' id='label_16_64_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_16_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Non'  id='choice_16_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_16_64_1' id='label_16_64_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_65'>Nom de l&#039;\u00e9cole<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_16_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_16_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dents ou zones \u00e0 traiter<\/h3><\/div><fieldset id=\"field_16_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline argylerow1 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_32'><div class='gchoice gchoice_16_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='18'  id='choice_16_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_1' id='label_16_32_1' class='gform-field-label gform-field-label--type-inline'>18<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='17'  id='choice_16_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_2' id='label_16_32_2' class='gform-field-label gform-field-label--type-inline'>17<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='16'  id='choice_16_32_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_3' id='label_16_32_3' class='gform-field-label gform-field-label--type-inline'>16<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.4' type='checkbox'  value='15'  id='choice_16_32_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_4' id='label_16_32_4' class='gform-field-label gform-field-label--type-inline'>15<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.5' type='checkbox'  value='14'  id='choice_16_32_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_5' id='label_16_32_5' class='gform-field-label gform-field-label--type-inline'>14<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.6' type='checkbox'  value='13'  id='choice_16_32_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_6' id='label_16_32_6' class='gform-field-label gform-field-label--type-inline'>13<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.7' type='checkbox'  value='12'  id='choice_16_32_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_7' id='label_16_32_7' class='gform-field-label gform-field-label--type-inline'>12<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.8' type='checkbox'  value='11'  id='choice_16_32_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_8' id='label_16_32_8' class='gform-field-label gform-field-label--type-inline'>11<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.9' type='checkbox'  value='21'  id='choice_16_32_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_9' id='label_16_32_9' class='gform-field-label gform-field-label--type-inline'>21<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.11' type='checkbox'  value='22'  id='choice_16_32_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_11' id='label_16_32_11' class='gform-field-label gform-field-label--type-inline'>22<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.12' type='checkbox'  value='23'  id='choice_16_32_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_12' id='label_16_32_12' class='gform-field-label gform-field-label--type-inline'>23<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.13' type='checkbox'  value='24'  id='choice_16_32_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_13' id='label_16_32_13' class='gform-field-label gform-field-label--type-inline'>24<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.14' type='checkbox'  value='25'  id='choice_16_32_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_14' id='label_16_32_14' class='gform-field-label gform-field-label--type-inline'>25<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.15' type='checkbox'  value='26'  id='choice_16_32_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_15' id='label_16_32_15' class='gform-field-label gform-field-label--type-inline'>26<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.16' type='checkbox'  value='27'  id='choice_16_32_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_16' id='label_16_32_16' class='gform-field-label gform-field-label--type-inline'>27<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_32_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.17' type='checkbox'  value='28'  id='choice_16_32_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_32_17' id='label_16_32_17' class='gform-field-label gform-field-label--type-inline'>28<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_16_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline argylerow2 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_34'><div class='gchoice gchoice_16_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='55'  id='choice_16_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_1' id='label_16_34_1' class='gform-field-label gform-field-label--type-inline'>55<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='54'  id='choice_16_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_2' id='label_16_34_2' class='gform-field-label gform-field-label--type-inline'>54<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='53'  id='choice_16_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_3' id='label_16_34_3' class='gform-field-label gform-field-label--type-inline'>53<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='52'  id='choice_16_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_4' id='label_16_34_4' class='gform-field-label gform-field-label--type-inline'>52<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.5' type='checkbox'  value='51'  id='choice_16_34_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_5' id='label_16_34_5' class='gform-field-label gform-field-label--type-inline'>51<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.6' type='checkbox'  value='61'  id='choice_16_34_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_6' id='label_16_34_6' class='gform-field-label gform-field-label--type-inline'>61<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.7' type='checkbox'  value='62'  id='choice_16_34_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_7' id='label_16_34_7' class='gform-field-label gform-field-label--type-inline'>62<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.8' type='checkbox'  value='63'  id='choice_16_34_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_8' id='label_16_34_8' class='gform-field-label gform-field-label--type-inline'>63<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.9' type='checkbox'  value='64'  id='choice_16_34_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_9' id='label_16_34_9' class='gform-field-label gform-field-label--type-inline'>64<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_34_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.11' type='checkbox'  value='65'  id='choice_16_34_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_34_11' id='label_16_34_11' class='gform-field-label gform-field-label--type-inline'>65<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_16_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline argylerow3 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_35'><div class='gchoice gchoice_16_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='85'  id='choice_16_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_1' id='label_16_35_1' class='gform-field-label gform-field-label--type-inline'>85<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='84'  id='choice_16_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_2' id='label_16_35_2' class='gform-field-label gform-field-label--type-inline'>84<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='83'  id='choice_16_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_3' id='label_16_35_3' class='gform-field-label gform-field-label--type-inline'>83<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='82'  id='choice_16_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_4' id='label_16_35_4' class='gform-field-label gform-field-label--type-inline'>82<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.5' type='checkbox'  value='81'  id='choice_16_35_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_5' id='label_16_35_5' class='gform-field-label gform-field-label--type-inline'>81<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.6' type='checkbox'  value='71'  id='choice_16_35_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_6' id='label_16_35_6' class='gform-field-label gform-field-label--type-inline'>71<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.7' type='checkbox'  value='72'  id='choice_16_35_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_7' id='label_16_35_7' class='gform-field-label gform-field-label--type-inline'>72<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.8' type='checkbox'  value='73'  id='choice_16_35_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_8' id='label_16_35_8' class='gform-field-label gform-field-label--type-inline'>73<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.9' type='checkbox'  value='74'  id='choice_16_35_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_9' id='label_16_35_9' class='gform-field-label gform-field-label--type-inline'>74<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_35_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.11' type='checkbox'  value='75'  id='choice_16_35_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_35_11' id='label_16_35_11' class='gform-field-label gform-field-label--type-inline'>75<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_16_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_inline argylerow4 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_36'><div class='gchoice gchoice_16_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='48'  id='choice_16_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_1' id='label_16_36_1' class='gform-field-label gform-field-label--type-inline'>48<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='47'  id='choice_16_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_2' id='label_16_36_2' class='gform-field-label gform-field-label--type-inline'>47<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='46'  id='choice_16_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_3' id='label_16_36_3' class='gform-field-label gform-field-label--type-inline'>46<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='45'  id='choice_16_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_4' id='label_16_36_4' class='gform-field-label gform-field-label--type-inline'>45<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.5' type='checkbox'  value='44'  id='choice_16_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_5' id='label_16_36_5' class='gform-field-label gform-field-label--type-inline'>44<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.6' type='checkbox'  value='43'  id='choice_16_36_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_6' id='label_16_36_6' class='gform-field-label gform-field-label--type-inline'>43<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.7' type='checkbox'  value='42'  id='choice_16_36_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_7' id='label_16_36_7' class='gform-field-label gform-field-label--type-inline'>42<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.8' type='checkbox'  value='41'  id='choice_16_36_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_8' id='label_16_36_8' class='gform-field-label gform-field-label--type-inline'>41<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.9' type='checkbox'  value='31'  id='choice_16_36_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_9' id='label_16_36_9' class='gform-field-label gform-field-label--type-inline'>31<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.11' type='checkbox'  value='32'  id='choice_16_36_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_11' id='label_16_36_11' class='gform-field-label gform-field-label--type-inline'>32<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.12' type='checkbox'  value='33'  id='choice_16_36_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_12' id='label_16_36_12' class='gform-field-label gform-field-label--type-inline'>33<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.13' type='checkbox'  value='34'  id='choice_16_36_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_13' id='label_16_36_13' class='gform-field-label gform-field-label--type-inline'>34<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.14' type='checkbox'  value='35'  id='choice_16_36_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_14' id='label_16_36_14' class='gform-field-label gform-field-label--type-inline'>35<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.15' type='checkbox'  value='36'  id='choice_16_36_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_15' id='label_16_36_15' class='gform-field-label gform-field-label--type-inline'>36<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.16' type='checkbox'  value='37'  id='choice_16_36_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_16' id='label_16_36_16' class='gform-field-label gform-field-label--type-inline'>37<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_36_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.17' type='checkbox'  value='38'  id='choice_16_36_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_36_17' id='label_16_36_17' class='gform-field-label gform-field-label--type-inline'>38<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information du Traitement<\/h3><\/div><fieldset id=\"field_16_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_4col 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' >S\u00e9lectionnez un ou plusieurs traitements :<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_16_22'><div class='gchoice gchoice_16_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Implants'  id='choice_16_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_1' id='label_16_22_1' class='gform-field-label gform-field-label--type-inline'>Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Extractions'  id='choice_16_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_2' id='label_16_22_2' class='gform-field-label gform-field-label--type-inline'>Extractions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Dents incluses'  id='choice_16_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_3' id='label_16_22_3' class='gform-field-label gform-field-label--type-inline'>Dents incluses<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='L\u00e9sion'  id='choice_16_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_4' id='label_16_22_4' class='gform-field-label gform-field-label--type-inline'>L\u00e9sion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='Chirurgie Orthognatique'  id='choice_16_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_5' id='label_16_22_5' class='gform-field-label gform-field-label--type-inline'>Chirurgie Orthognatique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.6' type='checkbox'  value='Infection'  id='choice_16_22_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_6' id='label_16_22_6' class='gform-field-label gform-field-label--type-inline'>Infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.7' type='checkbox'  value='Articulation Temporomandibulaire'  id='choice_16_22_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_7' id='label_16_22_7' class='gform-field-label gform-field-label--type-inline'>Articulation Temporomandibulaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.8' type='checkbox'  value='Apn\u00e9e du Sommeil'  id='choice_16_22_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_8' id='label_16_22_8' class='gform-field-label gform-field-label--type-inline'>Apn\u00e9e du Sommeil<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_16_22_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.9' type='checkbox'  value='Autres (s&#039;il vous pla\u00eet d\u00e9crire)'  id='choice_16_22_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_22_9' id='label_16_22_9' class='gform-field-label gform-field-label--type-inline'>Autres (s'il vous pla\u00eet d\u00e9crire)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_16_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_16_31'>Autres Commentaires :<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_16_31' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_16_42\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label 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