{"id":3730,"date":"2024-08-28T16:15:24","date_gmt":"2024-08-28T20:15:24","guid":{"rendered":"https:\/\/www.clinicdrbita.com\/formulaire-info-client\/"},"modified":"2024-08-29T11:26:04","modified_gmt":"2024-08-29T15:26:04","slug":"formulaire-info-client","status":"publish","type":"page","link":"https:\/\/www.clinicdrbita.com\/fr\/formulaire-info-client\/","title":{"rendered":"Formulaire info client"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3730\" class=\"elementor elementor-3730 elementor-3700\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9ff6325 e-flex e-con-boxed e-con e-parent\" data-id=\"9ff6325\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-90e4d8d elementor-widget elementor-widget-heading\" data-id=\"90e4d8d\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Formulaire de consentement<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2101125 elementor-widget elementor-widget-text-editor\" data-id=\"2101125\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Pour confirmer votre rendez-vous, veuillez remplir et soumettre le formulaire de consentement ci-dessous, ainsi que vos informations personnelles.<\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-dbf9c51 e-flex e-con-boxed e-con e-parent\" data-id=\"dbf9c51\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-50e9834 e-con-full e-flex e-con e-child\" data-id=\"50e9834\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3d95dd6 elementor-widget elementor-widget-shortcode\" data-id=\"3d95dd6\" data-element_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\"><div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_4_container\" data-token=\"4a37d87140da7d75cc66f63004389974\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate  frm_ajax_submit  frm_pro_form \" id=\"form_client-information-form2\" data-token=\"4a37d87140da7d75cc66f63004389974\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Client Information Form FR<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"4\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_4\" id=\"frm_hide_fields_4\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"client-information-form2\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_4\" name=\"frm_submit_entry_4\" value=\"02dfa18688\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/3730\" \/><div id=\"frm_field_48_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_qh4icy\" id=\"field_qh4icy_label\" class=\"frm_primary_label\">Pr\u00e9nom\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_qh4icy\" name=\"item_meta[48]\" value=\"\"  data-reqmsg=\"Pr\u00e9nom ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Pr\u00e9nom is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_3wneq\" id=\"field_3wneq_label\" class=\"frm_primary_label\">Nom de famille\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_3wneq\" name=\"item_meta[75]\" value=\"\"  data-reqmsg=\"Nom de famille ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Nom de famille is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_50_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<div  id=\"field_qk8pb2_label\" class=\"frm_primary_label\">Adresse\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<fieldset aria-labelledby=\"field_qk8pb2_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAdresse<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_50-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_qk8pb2_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAdresse de rue\t<\/label>\n\t\t<input type=\"text\" id=\"field_qk8pb2_line1\" value=\"\" name=\"item_meta[50][line1]\"  data-reqmsg=\"Adresse ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Adresse est non valide\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<div class=\"frm_description\">Adresse de rue<\/div><\/div>\n<div id=\"frm_field_50-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_qk8pb2_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAppartement\/Suite\/Num\u00e9ro d&#039;unit\u00e9 (si applicable)\t<\/label>\n\t\t<input type=\"text\" id=\"field_qk8pb2_line2\" value=\"\" name=\"item_meta[50][line2]\"  data-reqmsg=\"Adresse ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Adresse est non valide\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<div class=\"frm_description\">Appartement\/Suite\/Num\u00e9ro d'unit\u00e9 (si applicable)<\/div><\/div>\n<div id=\"frm_field_50-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_qk8pb2_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tVille\t<\/label>\n\t\t<input type=\"text\" id=\"field_qk8pb2_city\" value=\"\" name=\"item_meta[50][city]\"  data-reqmsg=\"Adresse ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Adresse est non valide\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">Ville<\/div><\/div>\n<div id=\"frm_field_50-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_qk8pb2_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tProvince\t<\/label>\n\t\t<input type=\"text\" id=\"field_qk8pb2_state\" value=\"\" name=\"item_meta[50][state]\"  data-reqmsg=\"Adresse ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Adresse est non valide\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">Province<\/div><\/div>\n<div id=\"frm_field_50-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_qk8pb2_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tCode postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_qk8pb2_zip\" value=\"\" name=\"item_meta[50][zip]\"  data-reqmsg=\"Adresse ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Adresse est non valide\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Code postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_51_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_nxmen2\" id=\"field_nxmen2_label\" class=\"frm_primary_label\">Date de naissance\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"text\" id=\"field_nxmen2\" name=\"item_meta[51]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"Date de naissance ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Date de naissance est invalide.\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_52_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n\t<label for=\"field_29yf4d3\" id=\"field_29yf4d3_label\" class=\"frm_primary_label\">Courriel\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"email\" id=\"field_29yf4d3\" name=\"item_meta[52]\" value=\"\"  data-reqmsg=\"Courriel ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Veuillez entrer une adresse e-mail valide.\" aria-invalid=\"false\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_53_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_vszsu2\" id=\"field_vszsu2_label\" class=\"frm_primary_label\">T\u00e9l\u00e9phone\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_vszsu2\" name=\"item_meta[53]\" value=\"\"  data-reqmsg=\"T\u00e9l\u00e9phone ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"T\u00e9l\u00e9phone est invalide.\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_54_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_bd7z32\" id=\"field_bd7z32_label\" class=\"frm_primary_label\">Les s\u00e9ances sont destin\u00e9es \u00e0: \r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t\t\t<select name=\"item_meta[54]\" id=\"field_bd7z32\"  data-placeholder=\"Choisir une option\"  placeholder=\"Choisir une option\" data-reqmsg=\"Les s\u00e9ances sont destin\u00e9es \u00e0:  ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Les s\u00e9ances sont destin\u00e9es \u00e0:  est non valide\" aria-invalid=\"false\"  >\n\t\t<option  class=\"frm-select-placeholder\" value=\"\" data-placeholder=\"true\">Choisir une option<\/option><option  value=\"Moi\">Moi<\/option><option  value=\"Mon enfant (14+)\">Mon enfant (14+)<\/option><option  value=\"Mon enfant (13-)\">Mon enfant (13-)<\/option><option  value=\"Mon compagnon et moi\">Mon compagnon et moi<\/option><option  value=\"Ma famille\">Ma famille<\/option>\t<\/select>\n\t\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_55_container\" class=\"frm_form_field form-field  frm_top_container frm_full\">\r\n\t<label for=\"field_9jv0r13\" id=\"field_9jv0r13_label\" class=\"frm_primary_label\">Si vous avez s\u00e9lectionn\u00e9 une option autre que \"Moi\", veuillez entrer leurs noms ci-dessous (s\u00e9par\u00e9s par une virgule)\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[55]\" id=\"field_9jv0r13\" rows=\"5\"  data-invmsg=\"Si vous avez s\u00e9lectionn\u00e9 une option autre que &quot;Moi&quot;, veuillez entrer leurs noms ci-dessous (s\u00e9par\u00e9s par une virgule) ne peut pas \u00eatre vide.\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_56_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_kw9tf2_label\" class=\"frm_primary_label\">Sexe\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_kw9tf2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_56-0\">\t\t\t<label  for=\"field_kw9tf2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[56]\" id=\"field_kw9tf2-0\" value=\"Masculin\"\n\t\t   data-reqmsg=\"Sexe ne peut pas \u00eatre vide.\" data-invmsg=\"Sexe est non valide\" aria-invalid=\"false\"  \/> Masculin<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_56-1\">\t\t\t<label  for=\"field_kw9tf2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[56]\" id=\"field_kw9tf2-1\" value=\"F\u00e9minin\"\n\t\t   data-reqmsg=\"Sexe ne peut pas \u00eatre vide.\" data-invmsg=\"Sexe est non valide\" aria-invalid=\"false\"  \/> F\u00e9minin<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_56-2\">\t\t\t<label  for=\"field_kw9tf2-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[56]\" id=\"field_kw9tf2-2\" value=\"Autre\"\n\t\t   data-reqmsg=\"Sexe ne peut pas \u00eatre vide.\" data-invmsg=\"Sexe est non valide\" aria-invalid=\"false\"  \/> Autre<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_57_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio frm_other_container\">\r\n\t<div  id=\"field_f92bi2_label\" class=\"frm_primary_label\">\u00c9tat civil\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_f92bi2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_57-0\">\t\t\t<label  for=\"field_f92bi2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[57]\" id=\"field_f92bi2-0\" value=\"Mari\u00e9(e)\"\n\t\t   data-reqmsg=\"\u00c9tat civil ne peut pas \u00eatre vide.\" data-invmsg=\"\u00c9tat civil est non valide\" aria-invalid=\"false\"  \/> Mari\u00e9(e)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_57-1\">\t\t\t<label  for=\"field_f92bi2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[57]\" id=\"field_f92bi2-1\" value=\"Divorc\u00e9(e)\"\n\t\t   data-reqmsg=\"\u00c9tat civil ne peut pas \u00eatre vide.\" data-invmsg=\"\u00c9tat civil est non valide\" aria-invalid=\"false\"  \/> Divorc\u00e9(e)<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_57-other_2\">\t\t\t<label  for=\"field_f92bi2-other_2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[57]\" id=\"field_f92bi2-other_2\" value=\"Autre\"\n\t\t   data-reqmsg=\"\u00c9tat civil ne peut pas \u00eatre vide.\" data-invmsg=\"\u00c9tat civil est non valide\" aria-invalid=\"false\"  \/> Autre<\/label><label for=\"field_f92bi2-other_2-otext\" class=\"frm_screen_reader frm_hidden\">Autre<\/label><input type=\"text\" id=\"field_f92bi2-other_2-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][57]\" value=\"\" \/><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_58_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_full\">\r\n\t<label for=\"field_e6lis6\" id=\"field_e6lis6_label\" class=\"frm_primary_label\">Nombre d'enfants\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_e6lis6\" name=\"item_meta[58]\" value=\"\"  data-reqmsg=\"Nombre d&#039;enfants ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Nombre d&#039;enfants is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_59_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_wn9bf2\" id=\"field_wn9bf2_label\" class=\"frm_primary_label\">Niveau d'\u00e9ducation\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_wn9bf2\" name=\"item_meta[59]\" value=\"\"  data-reqmsg=\"Niveau d&#039;\u00e9ducation ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Niveau d&#039;\u00e9ducation is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_60_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_8q96a2\" id=\"field_8q96a2_label\" class=\"frm_primary_label\">Profession\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_8q96a2\" name=\"item_meta[60]\" value=\"\"  data-reqmsg=\"Profession ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Profession is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_61_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n\t<label for=\"field_9t1lx2\" id=\"field_9t1lx2_label\" class=\"frm_primary_label\">R\u00e9sultat de votre dernier examen m\u00e9dical (si applicable):\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_9t1lx2\" name=\"item_meta[61]\" value=\"\"  data-invmsg=\"R\u00e9sultat de votre dernier examen m\u00e9dical (si applicable): is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_62_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_xyff2\" id=\"field_xyff2_label\" class=\"frm_primary_label\">Ant\u00e9c\u00e9dents familiaux de sant\u00e9 physique et mentale:\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<textarea name=\"item_meta[62]\" id=\"field_xyff2\" rows=\"5\"  data-reqmsg=\"Ant\u00e9c\u00e9dents familiaux de sant\u00e9 physique et mentale: ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Ant\u00e9c\u00e9dents familiaux de sant\u00e9 physique et mentale: est invalide.\" aria-invalid=\"false\"  ><\/textarea>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_63_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n\t<label for=\"field_verh62\" id=\"field_verh62_label\" class=\"frm_primary_label\">Comment avez-vous entendu parler de nous?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_verh62\" name=\"item_meta[63]\" value=\"\"  data-reqmsg=\"Comment avez-vous entendu parler de nous? ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Comment avez-vous entendu parler de nous? is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_64_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n\t<label for=\"field_w875g2\" id=\"field_w875g2_label\" class=\"frm_primary_label\">Nom de la personne \u00e0 contacter en cas d'urgence\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input  type=\"text\" id=\"field_w875g2\" name=\"item_meta[64]\" value=\"\"  data-reqmsg=\"Nom de la personne \u00e0 contacter en cas d&#039;urgence ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"Nom de la personne \u00e0 contacter en cas d&#039;urgence is invalid\" aria-invalid=\"false\"   \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n\t<label for=\"field_f40cm2\" id=\"field_f40cm2_label\" class=\"frm_primary_label\">T\u00e9l\u00e9phone de la personne \u00e0 contacter en cas d'urgence\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/label>\r\n\t<input type=\"tel\" id=\"field_f40cm2\" name=\"item_meta[65]\" value=\"\"  data-reqmsg=\"T\u00e9l\u00e9phone de la personne \u00e0 contacter en cas d&#039;urgence ne peut pas \u00eatre vide.\" aria-required=\"true\" data-invmsg=\"T\u00e9l\u00e9phone de la personne \u00e0 contacter en cas d&#039;urgence est invalide.\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field  frm_html_container form-field\">Notre clinique adopte une approche syst\u00e9mique de la th\u00e9rapie, il est donc essentiel que les deux parents soient dispos\u00e9s \u00e0 travailler ensemble afin de fournir les meilleurs soins possibles \u00e0 leur enfant. Si vous soumettez ces informations au nom d\u2019un enfant de moins de 14 ans, vous devez r\u00e9pondre aux crit\u00e8res suivants pour que nous puissions accepter votre dossier :<\/p>\n<p>- Vous avez inform\u00e9 et obtenu le consentement de l\u2019autre parent ou tuteur l\u00e9gal, si celui-ci existe;<\/p>\n<p>- Vous \u00eates en bons termes et capable de collaborer avec l'autre parent ou tuteur l\u00e9gal, si celui-ci existe.<\/p><\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_pgijw2_label\" class=\"frm_primary_label\">Remplissez-vous ces crit\u00e8res?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_pgijw2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_67-0\">\t\t\t<label  for=\"field_pgijw2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[67]\" id=\"field_pgijw2-0\" value=\"Oui\"\n\t\t   data-reqmsg=\"Remplissez-vous ces crit\u00e8res? ne peut pas \u00eatre vide.\" data-invmsg=\"Remplissez-vous ces crit\u00e8res? est non valide\" aria-invalid=\"false\"  \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_67-1\">\t\t\t<label  for=\"field_pgijw2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[67]\" id=\"field_pgijw2-1\" value=\"Ne s\u2019applique pas\"\n\t\t   data-reqmsg=\"Remplissez-vous ces crit\u00e8res? ne peut pas \u00eatre vide.\" data-invmsg=\"Remplissez-vous ces crit\u00e8res? est non valide\" aria-invalid=\"false\"  \/> Ne s\u2019applique pas<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_2fhn92_label\" class=\"frm_primary_label\">Nous n'acceptons pas les cas impos\u00e9s par un tribunal. Avez-vous \u00e9t\u00e9 mandat\u00e9(e) par un tribunal?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_2fhn92_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_68-0\">\t\t\t<label  for=\"field_2fhn92-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[68]\" id=\"field_2fhn92-0\" value=\"Non\"\n\t\t   data-reqmsg=\"Nous n&#039;acceptons pas les cas impos\u00e9s par un tribunal. Avez-vous \u00e9t\u00e9 mandat\u00e9(e) par un tribunal? ne peut pas \u00eatre vide.\" data-invmsg=\"Nous n&#039;acceptons pas les cas impos\u00e9s par un tribunal. Avez-vous \u00e9t\u00e9 mandat\u00e9(e) par un tribunal? est non valide\" aria-invalid=\"false\"  \/> Non<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_68-1\">\t\t\t<label  for=\"field_2fhn92-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[68]\" id=\"field_2fhn92-1\" value=\"Oui\"\n\t\t   data-reqmsg=\"Nous n&#039;acceptons pas les cas impos\u00e9s par un tribunal. Avez-vous \u00e9t\u00e9 mandat\u00e9(e) par un tribunal? ne peut pas \u00eatre vide.\" data-invmsg=\"Nous n&#039;acceptons pas les cas impos\u00e9s par un tribunal. Avez-vous \u00e9t\u00e9 mandat\u00e9(e) par un tribunal? est non valide\" aria-invalid=\"false\"  \/> Oui<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field  frm_html_container form-field\">Nous n'acceptons pas les cas impos\u00e9s par un tribunal.<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_2atvp2_label\" class=\"frm_primary_label\">Vous pouvez annuler votre rendez-vous sans frais si vous l'annulez au moins 24 heures \u00e0 l'avance. Si vous annulez dans les 24 heures pr\u00e9c\u00e9dant votre rendez-vous, acceptez-vous de payer les frais de la s\u00e9ance?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_2atvp2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_70-0\">\t\t\t<label  for=\"field_2atvp2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[70]\" id=\"field_2atvp2-0\" value=\"J&#039;accepte\"\n\t\t   data-reqmsg=\"Vous pouvez annuler votre rendez-vous sans frais si vous l&#039;annulez au moins 24 heures \u00e0 l&#039;avance. Si vous annulez dans les 24 heures pr\u00e9c\u00e9dant votre rendez-vous, acceptez-vous de payer les frais de la s\u00e9ance? ne peut pas \u00eatre vide.\" data-invmsg=\"Vous pouvez annuler votre rendez-vous sans frais si vous l&#039;annulez au moins 24 heures \u00e0 l&#039;avance. Si vous annulez dans les 24 heures pr\u00e9c\u00e9dant votre rendez-vous, acceptez-vous de payer les frais de la s\u00e9ance? est non valide\" aria-invalid=\"false\"  \/> J'accepte<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_71_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_bgpst2_label\" class=\"frm_primary_label\">Acceptez-vous que les frais d'annulation soient pr\u00e9lev\u00e9s sur votre carte de cr\u00e9dit?\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_bgpst2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_71-0\">\t\t\t<label  for=\"field_bgpst2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[71]\" id=\"field_bgpst2-0\" value=\"J&#039;accepte\"\n\t\t   data-reqmsg=\"Acceptez-vous que les frais d&#039;annulation soient pr\u00e9lev\u00e9s sur votre carte de cr\u00e9dit? ne peut pas \u00eatre vide.\" data-invmsg=\"Acceptez-vous que les frais d&#039;annulation soient pr\u00e9lev\u00e9s sur votre carte de cr\u00e9dit? est non valide\" aria-invalid=\"false\"  \/> J'accepte<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n\t<div  id=\"field_xa2v72_label\" class=\"frm_primary_label\"><p>J'ai lu, compris et accept\u00e9 les conditions d'utilisation (<a target=\"_blank\" rel=\"noopener noreferrer\" href=\"https:\/\/www.clinicdrbita.com\/fr\/conditions\/\"><u>CDU<\/u><\/a>). Je comprends \u00e9galement que le bouton \"SOUMETTRE\" est l'\u00e9quivalent \u00e9lectronique de ma signature. En le cliquant, je certifie et confirme mon accord avec les <a target=\"_blank\" rel=\"noopener noreferrer\" href=\"https:\/\/www.clinicdrbita.com\/fr\/conditions\/\"><u>CDU<\/u><\/a>.\r\n\t\t<span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n\t<\/div>\r\n\t<div class=\"frm_opt_container\" aria-labelledby=\"field_xa2v72_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_72-0\">\t\t\t<label  for=\"field_xa2v72-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[72]\" id=\"field_xa2v72-0\" value=\"Oui\"\n\t\t   data-reqmsg=\"&lt;p&gt;J&#039;ai lu, compris et accept\u00e9 les conditions d&#039;utilisation (&lt;a target=&quot;_blank&quot; rel=&quot;noopener noreferrer&quot; href=&quot;https:\/\/www.clinicdrbita.com\/fr\/conditions\/&quot;&gt;&lt;u&gt;CDU&lt;\/u&gt;&lt;\/a&gt;). Je comprends \u00e9galement que le bouton &quot;SOUMETTRE&quot; est l&#039;\u00e9quivalent \u00e9lectronique de ma signature. En le cliquant, je certifie et confirme mon accord avec les &lt;a target=&quot;_blank&quot; rel=&quot;noopener noreferrer&quot; href=&quot;https:\/\/www.clinicdrbita.com\/fr\/conditions\/&quot;&gt;&lt;u&gt;CDU&lt;\/u&gt;&lt;\/a&gt;. ne peut pas \u00eatre vide.\" data-invmsg=\"&lt;p&gt;J&#039;ai lu, compris et accept\u00e9 les conditions d&#039;utilisation (&lt;a target=&quot;_blank&quot; rel=&quot;noopener noreferrer&quot; href=&quot;https:\/\/www.clinicdrbita.com\/fr\/conditions\/&quot;&gt;&lt;u&gt;CDU&lt;\/u&gt;&lt;\/a&gt;). Je comprends \u00e9galement que le bouton &quot;SOUMETTRE&quot; est l&#039;\u00e9quivalent \u00e9lectronique de ma signature. En le cliquant, je certifie et confirme mon accord avec les &lt;a target=&quot;_blank&quot; rel=&quot;noopener noreferrer&quot; href=&quot;https:\/\/www.clinicdrbita.com\/fr\/conditions\/&quot;&gt;&lt;u&gt;CDU&lt;\/u&gt;&lt;\/a&gt;. est non valide\" aria-invalid=\"false\"  \/> Oui<\/label><\/div>\n<\/div>\r\n\t\r\n\t\r\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_none_container\">\n\t<label for=\"g-recaptcha-response\" id=\"field_5xk9k_label\" class=\"frm_primary_label\">Captcha\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<div  id=\"field_5xk9k\" class=\"frm-g-recaptcha\" data-sitekey=\"6Lcg66kqAAAAAMuQASlESWUVZdPFHm9CXNhkKp8N\" data-size=\"invisible\" data-theme=\"light\"><\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_73_container\" class=\"frm_form_field form-field \">\r\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Submit<\/button>\r\n\r\n<\/div>\r\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__66719187526a2\">\n\t\t\t\t<label for=\"frm_email_4\" >\n\t\t\t\t\tSi vous \u00eates un humain, ne remplissez pas ce champ.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_4\" type=\"email\" class=\"frm_verify\" name=\"frm__66719187526a2\" value=\"\"  \/>\n\t\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"9\/7IX\/cBvfDkQD+Mxy2xSInZTLauilFqrNYPS7mVhcQ=\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Formulaire de consentement Pour confirmer votre rendez-vous, veuillez remplir et soumettre le formulaire de consentement ci-dessous, ainsi que vos informations personnelles.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":10,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-3730","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Formulaire info client | Clinic Dr Bita<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.clinicdrbita.com\/client-information-form\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Formulaire info client | Clinic Dr Bita\" \/>\n<meta property=\"og:description\" content=\"Formulaire de consentement Pour confirmer votre rendez-vous, veuillez remplir et 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