{"id":1678,"date":"2020-09-16T17:03:53","date_gmt":"2020-09-16T17:03:53","guid":{"rendered":"https:\/\/cliniquepodiatriquedelaval.com\/?page_id=1678"},"modified":"2021-05-12T17:34:19","modified_gmt":"2021-05-12T17:34:19","slug":"new-patient-2020-opening-a-file","status":"publish","type":"page","link":"https:\/\/cliniquepodiatriquedelaval.com\/en\/new-patient-2020-opening-a-file\/","title":{"rendered":"NEW PATIENT 2020 Opening a file"},"content":{"rendered":"<p><span style=\"vertical-align: inherit;\"><span style=\"vertical-align: inherit;\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/1678#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_2_2\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_2'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_2_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_2_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_2_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_2' class='gform_hidden' value='https:\/\/cliniquepodiatriquedelaval.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">I. INFORMATIONS PERSONNELLES<\/h2><\/li><li id=\"field_2_52\" class=\"gfield gfield--type-text gf_left_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_2_52'>Pr\u00e9nom<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_53\" class=\"gfield gfield--type-text gf_right_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_2_53'>Nom<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_2_53' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_7\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_left_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_2_7'>Date de naissance<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_2_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_7_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_7_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_7' class='gform_hidden' value='https:\/\/cliniquepodiatriquedelaval.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_2_8\" class=\"gfield gfield--type-text gf_right_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_2_8'>\u00c2ge<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-radio gfield--type-choice gf_left_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sexe<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_10'>\n\t\t\t<li class='gchoice gchoice_2_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='F'  id='choice_2_10_0'    \/>\n\t\t\t\t<label for='choice_2_10_0' id='label_2_10_0' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='H'  id='choice_2_10_1'    \/>\n\t\t\t\t<label for='choice_2_10_1' id='label_2_10_1' class='gform-field-label gform-field-label--type-inline'>H<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-text gf_right_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_2_12'>Poids (lbs)<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_26\" class=\"gfield gfield--type-phone gf_left_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_2_26'># de t\u00e9l\u00e9phone primaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_26' id='input_2_26' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_27\" class=\"gfield gfield--type-phone gf_right_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_2_27'>Cellulaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_2_27' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-text gf_left_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_2_14'>Courriel<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-text gf_right_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_2_15'>Pointure chaussures<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_18\" class=\"gfield gfield--type-text gf_left_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_2_18'>Adresse<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_20\" class=\"gfield gfield--type-text gf_middle_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_2_20'>Ville<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_2_20' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_19\" class=\"gfield gfield--type-text gf_right_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_2_19'>Code postal<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-text gf_left_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_2_16'>Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_22\" class=\"gfield gfield--type-radio gfield--type-choice gf_right_half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Avez-vous des assurances?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_22'>\n\t\t\t<li class='gchoice gchoice_2_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='oui'  id='choice_2_22_0'    \/>\n\t\t\t\t<label for='choice_2_22_0' id='label_2_22_0' class='gform-field-label gform-field-label--type-inline'>oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='non'  id='choice_2_22_1'    \/>\n\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_23\" class=\"gfield gfield--type-text gf_left_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_2_23'>Contact d\u2019urgence<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_2_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_25\" class=\"gfield gfield--type-phone gf_right_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_2_25'># t\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_2_25' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>Lien de parent\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_30\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >R\u00e9f\u00e9rence<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_30'>\n\t\t\t<li class='gchoice gchoice_2_30_0'>\n\t\t\t\t<input name='input_30' type='radio' value='Ami'  id='choice_2_30_0'    \/>\n\t\t\t\t<label for='choice_2_30_0' id='label_2_30_0' class='gform-field-label gform-field-label--type-inline'>Ami<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_1'>\n\t\t\t\t<input name='input_30' type='radio' value='Famille'  id='choice_2_30_1'    \/>\n\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_2'>\n\t\t\t\t<input name='input_30' type='radio' value='En passant'  id='choice_2_30_2'    \/>\n\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>En passant<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_3'>\n\t\t\t\t<input name='input_30' type='radio' value='Internet'  id='choice_2_30_3'    \/>\n\t\t\t\t<label for='choice_2_30_3' id='label_2_30_3' class='gform-field-label gform-field-label--type-inline'>Internet<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_4'>\n\t\t\t\t<input name='input_30' type='radio' value='Pages Jaune'  id='choice_2_30_4'    \/>\n\t\t\t\t<label for='choice_2_30_4' id='label_2_30_4' class='gform-field-label gform-field-label--type-inline'>Pages Jaune<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_5'>\n\t\t\t\t<input name='input_30' type='radio' value='Brochure'  id='choice_2_30_5'    \/>\n\t\t\t\t<label for='choice_2_30_5' id='label_2_30_5' class='gform-field-label gform-field-label--type-inline'>Brochure<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_30_6'>\n\t\t\t\t<input name='input_30' type='radio' value='gf_other_choice'  id='choice_2_30_6'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_2_30_other' name='input_30_other' type='text' value='Other health professional' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other health professional\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other health professional\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_31\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">II. HISTORIQUE M\u00c9DICAL<\/h2><\/li><li id=\"field_2_32\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Douleur<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_32'>\n\t\t\t<li class='gchoice gchoice_2_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Aucune'  id='choice_2_32_0'    \/>\n\t\t\t\t<label for='choice_2_32_0' id='label_2_32_0' class='gform-field-label gform-field-label--type-inline'>Aucune<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Intermittente'  id='choice_2_32_1'    \/>\n\t\t\t\t<label for='choice_2_32_1' id='label_2_32_1' class='gform-field-label gform-field-label--type-inline'>Intermittente<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_32_2'>\n\t\t\t\t<input name='input_32' type='radio' value='Constante'  id='choice_2_32_2'    \/>\n\t\t\t\t<label for='choice_2_32_2' id='label_2_32_2' class='gform-field-label gform-field-label--type-inline'>Constante<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_33\" class=\"gfield gfield--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_2_33'>Motif de consultation (Ongles incarn\u00e9s, Verrues, cors, autres) :<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_2_33' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_34\" class=\"gfield gfield--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_2_34'>ALLERGIES<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_2_34' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_36\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Cochez la (les) condition(s) m\u00e9dicale(s) qui vous concerne<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_36'><li class='gchoice gchoice_2_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Diab\u00e8te'  id='choice_2_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_1' id='label_2_36_1' class='gform-field-label gform-field-label--type-inline'>Diab\u00e8te<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Hypercholest\u00e9rol\u00e9mie'  id='choice_2_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_2' id='label_2_36_2' class='gform-field-label gform-field-label--type-inline'>Hypercholest\u00e9rol\u00e9mie<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Hypertension art\u00e9rielle'  id='choice_2_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_3' id='label_2_36_3' class='gform-field-label gform-field-label--type-inline'>Hypertension art\u00e9rielle<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='Insuffisance art\u00e9rielle'  id='choice_2_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_4' id='label_2_36_4' class='gform-field-label gform-field-label--type-inline'>Insuffisance art\u00e9rielle<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.5' type='checkbox'  value='Insuffisance veineuse'  id='choice_2_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_5' id='label_2_36_5' class='gform-field-label gform-field-label--type-inline'>Insuffisance veineuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.6' type='checkbox'  value='Caillots sanguins'  id='choice_2_36_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_6' id='label_2_36_6' class='gform-field-label gform-field-label--type-inline'>Caillots sanguins<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.7' type='checkbox'  value='Maladie cardiaque'  id='choice_2_36_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_7' id='label_2_36_7' class='gform-field-label gform-field-label--type-inline'>Maladie cardiaque<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.8' type='checkbox'  value='Maladie h\u00e9patique'  id='choice_2_36_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_8' id='label_2_36_8' class='gform-field-label gform-field-label--type-inline'>Maladie h\u00e9patique<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.9' type='checkbox'  value='Insuffisance r\u00e9nale'  id='choice_2_36_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_9' id='label_2_36_9' class='gform-field-label gform-field-label--type-inline'>Insuffisance r\u00e9nale<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.11' type='checkbox'  value='Arthrose'  id='choice_2_36_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_11' id='label_2_36_11' class='gform-field-label gform-field-label--type-inline'>Arthrose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.12' type='checkbox'  value='Arthrite rhumato\u00efde'  id='choice_2_36_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_12' id='label_2_36_12' class='gform-field-label gform-field-label--type-inline'>Arthrite rhumato\u00efde<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.13' type='checkbox'  value='Goutte'  id='choice_2_36_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_13' id='label_2_36_13' class='gform-field-label gform-field-label--type-inline'>Goutte<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.14' type='checkbox'  value='Ost\u00e9oporose'  id='choice_2_36_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_14' id='label_2_36_14' class='gform-field-label gform-field-label--type-inline'>Ost\u00e9oporose<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.15' type='checkbox'  value='Ulc\u00e8res ou br\u00fblures d\u2019estomac'  id='choice_2_36_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_15' id='label_2_36_15' class='gform-field-label gform-field-label--type-inline'>Ulc\u00e8res ou br\u00fblures d\u2019estomac<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.16' type='checkbox'  value='Psoriasis'  id='choice_2_36_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_16' id='label_2_36_16' class='gform-field-label gform-field-label--type-inline'>Psoriasis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.17' type='checkbox'  value='Ecz\u00e9ma'  id='choice_2_36_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_17' id='label_2_36_17' class='gform-field-label gform-field-label--type-inline'>Ecz\u00e9ma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.18' type='checkbox'  value='Enceinte\/Allaite'  id='choice_2_36_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_18' id='label_2_36_18' class='gform-field-label gform-field-label--type-inline'>Enceinte\/Allaite<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_36_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.19' type='checkbox'  value='Autre'  id='choice_2_36_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_36_19' id='label_2_36_19' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_38\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'>Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_39\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00cates-vous enceinte?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_39'>\n\t\t\t<li class='gchoice gchoice_2_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='oui'  id='choice_2_39_0'    \/>\n\t\t\t\t<label for='choice_2_39_0' id='label_2_39_0' class='gform-field-label gform-field-label--type-inline'>oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='non'  id='choice_2_39_1'    \/>\n\t\t\t\t<label for='choice_2_39_1' id='label_2_39_1' class='gform-field-label gform-field-label--type-inline'>non<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_39_2'>\n\t\t\t\t<input name='input_39' type='radio' value='Allaitement'  id='choice_2_39_2'    \/>\n\t\t\t\t<label for='choice_2_39_2' id='label_2_39_2' class='gform-field-label gform-field-label--type-inline'>Allaitement<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_40\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'>(mois)<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_41\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >M\u00e9dicaments<\/li><li id=\"field_2_42\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >\u00c9crivez les noms des m\u00e9dicaments que vous prenez si vous n\u2019avez pas amen\u00e9 votre liste du pharmacien<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_2_42'>\n\t\t\t<li class='gchoice gchoice_2_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='Je ne prends aucun m\u00e9dicament'  id='choice_2_42_0'    \/>\n\t\t\t\t<label for='choice_2_42_0' id='label_2_42_0' class='gform-field-label gform-field-label--type-inline'>Je ne prends aucun m\u00e9dicament<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='J\u2019ai amen\u00e9 ma liste des m\u00e9dicaments'  id='choice_2_42_1'    \/>\n\t\t\t\t<label for='choice_2_42_1' id='label_2_42_1' class='gform-field-label gform-field-label--type-inline'>J\u2019ai amen\u00e9 ma liste des m\u00e9dicaments<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_2_42_2'>\n\t\t\t\t<input name='input_42' type='radio' value='Mes m\u00e9dicaments'  id='choice_2_42_2'    \/>\n\t\t\t\t<label for='choice_2_42_2' id='label_2_42_2' class='gform-field-label gform-field-label--type-inline'>Mes m\u00e9dicaments<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_43\" class=\"gfield gfield--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_2_43'>Mes m\u00e9dicaments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_2_43' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_2_44\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">III. CONTACTS M\u00c9DICAUX<\/h2><\/li><li id=\"field_2_45\" class=\"gfield gfield--type-text gf_left_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_2_45'>M\u00e9decin de famille<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_46\" class=\"gfield gfield--type-text gf_right_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_2_46'>M\u00e9decin sp\u00e9cialiste<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_47\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">IV. AUTORISATION<\/h2><\/li><li id=\"field_2_48\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_48'><li class='gchoice gchoice_2_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='J\u2019autorise mon podiatre \u00e0 documenter mes l\u00e9sions \u00e0 l\u2019aide de photos ou de vid\u00e9os si n\u00e9cessaire.'  id='choice_2_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1' class='gform-field-label gform-field-label--type-inline'>J\u2019autorise mon podiatre \u00e0 documenter mes l\u00e9sions \u00e0 l\u2019aide de photos ou de vid\u00e9os si n\u00e9cessaire.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_49\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">V. SIGNATURE DU PATIENT<\/h2><\/li><li id=\"field_2_50\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_2_50'><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_2_51\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >* En apposant ma signature, je consens \u00e0 r\u00e9gler les frais reli\u00e9s \u00e0 la consultation. (En apposant ma signature, je consens \u00e0 r\u00e9gler les frais reli\u00e9s \u00e0 la\nconsultation de base et aux frais connexes s\u2019il y a lieu, d\u00fb au diagnostic du clinicien.) \u2020Le parent doit signer si l\u2019enfant \u00e0 moins de 14 ans.\n+VEUILLEZ NOTER QUE DES FRAIS DE 40$ PEUVENT \u00caTRE APPLICABLES LORS DE RETARD OU ABSENCE.<\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Envoyer'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=8decae6b8fc3a27b1df9a6f3d72efaab' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='cnmNRSskkSSZGt6e71BZLO5FqkXNRzo3qXquUPzX9YB1uVNCBTClxeRss3tWY39x9po+8r\/XlslLEdPeOV9Gn3SON96tuUxm5XcwG8N1vnY61Wg=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_2' value='WyJbXSIsIjI4Y2Q3NjViMDczZGNiOGUyOTRmNzg0NmNkMDYzYzUyIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_2' id='gform_target_page_number_2' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_2' id='gform_source_page_number_2' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <input\n                    class=\"apbct_special_field apbct_email_id__gravity_form\"\n                    name=\"apbct__email_id__gravity_form\"\n                    aria-label=\"apbct__label_id__gravity_form\"\n                    type=\"text\" size=\"30\" maxlength=\"200\" autocomplete=\"off\"\n                    value=\"\"\n                \/><\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_2' id='gform_ajax_frame_2' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https:\/\/cliniquepodiatriquedelaval.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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HISTORIQUE...","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1678","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/cliniquepodiatriquedelaval.com\/en\/wp-json\/wp\/v2\/pages\/1678","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cliniquepodiatriquedelaval.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cliniquepodiatriquedelaval.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cliniquepodiatriquedelaval.com\/en\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/cliniquepodiatriquedelaval.com\/en\/wp-json\/wp\/v2\/comments?post=1678"}],"version-history":[{"count":0,"href":"https:\/\/cliniquepodiatriquedelaval.com\/en\/wp-json\/wp\/v2\/pages\/1678\/revisions"}],"wp:attachment":[{"href":"https:\/\/cliniquepodiatriquedelaval.com\/en\/wp-json\/wp\/v2\/media?parent=1678"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}