{"id":3569,"date":"2015-01-25T16:01:38","date_gmt":"2015-01-25T20:01:38","guid":{"rendered":"http:\/\/frederictonoralsurgery.com\/online-doctor-referral-form"},"modified":"2024-01-24T12:06:14","modified_gmt":"2024-01-24T16:06:14","slug":"formulaire-de-reference","status":"publish","type":"page","link":"https:\/\/frederictonoralsurgery.com\/fr\/contactez-nous\/formulaire-de-reference","title":{"rendered":"Formulaire de reference"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:40px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_2_5 2_5 fusion-two-fifth fusion-column-first\" style=\"--awb-bg-size:cover;--awb-margin-bottom:0px;width:37.6%; margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-1\"><p><strong>Clinique de chirurgie buccale de Fredericton<\/strong><br \/>123 rue York, #200<br \/>Fredericton, N.-B. E3B 3N6<\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_3 1_3 fusion-one-third\" style=\"--awb-bg-size:cover;--awb-margin-bottom:0px;width:30.6666%; margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-2\"><p>T: 506-458-8864<br \/>\nF: 506-450-0313<\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-last\" style=\"--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-3\"><div id=\"piotnetforms\" class=\"piotnetforms piotnetforms-5272\" data-piotnetforms-shortcode-id=\"5272\"><form id=\"Doctor Referral Form (FR)\" class=\"piotnetforms__form\" onsubmit=\"return false\"><div class=\"piotnet-section p83330469\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p10158236\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t\n\t\t<div class=\"p72105764 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-radio piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-doctor piotnetforms-col-100\">\n\t\t\t\t<label for=\"form-field-doctor\" class=\"piotnetforms-field-label\">Chirurgien de pr\u00e9f\u00e9rence:<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><script type=\"text\/javascript\">if(void 0===clearValidity)function clearValidity(i){jQuery(i).closest(\".piotnetforms-field-subgroup\").find(\".piotnetforms-field-option input\").each((function(){jQuery(this)[0].setCustomValidity(\"\")}))}<\/script><div class=\"piotnetforms-field-subgroup piotnetforms-field-subgroup--native  piotnetforms-field-subgroup--checkbox-replacement piotnetforms-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Dr. Martin Belanger\" data-value=\"Dr. Martin Belanger\" id=\"form-field-doctor-0\" name=\"form_fields[doctor]\" data-piotnetforms-default-value=\"No Preference\" data-piotnetforms-send-data-by-label=\"Dr. Martin Belanger\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-doctor-0\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Dr. Martin Belanger<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Dr. Nach Daniel\" data-value=\"Dr. Nach Daniel\" id=\"form-field-doctor-1\" name=\"form_fields[doctor]\" data-piotnetforms-default-value=\"No Preference\" data-piotnetforms-send-data-by-label=\"Dr. Nach Daniel\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-doctor-1\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Dr. Nach Daniel<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Dr. Karim Al-Khatib\" data-value=\"Dr. Karim Al-Khatib\" id=\"form-field-doctor-2\" name=\"form_fields[doctor]\" data-piotnetforms-default-value=\"No Preference\" data-piotnetforms-send-data-by-label=\"Dr. Karim Al-Khatib\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-doctor-2\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Dr. Karim Al-Khatib<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Dr. Johnson Cheung\" data-value=\"Dr. Johnson Cheung\" id=\"form-field-doctor-3\" name=\"form_fields[doctor]\" data-piotnetforms-default-value=\"No Preference\" data-piotnetforms-send-data-by-label=\"Dr. Johnson Cheung\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-doctor-3\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Dr. Johnson Cheung<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Dr. Scott Kirby\" data-value=\"Dr. Scott Kirby\" id=\"form-field-doctor-4\" name=\"form_fields[doctor]\" data-piotnetforms-default-value=\"No Preference\" data-piotnetforms-send-data-by-label=\"Dr. Scott Kirby\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-doctor-4\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Dr. Scott Kirby<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"No Preference\" data-value=\"No Preference\" id=\"form-field-doctor-5\" name=\"form_fields[doctor]\" data-piotnetforms-default-value=\"No Preference\" checked=\"checked checked\" data-checked=\"checked checked\" data-piotnetforms-send-data-by-label=\"No Preference\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-doctor-5\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>No Preference<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<div class=\"piotnet-section p23292264\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p48452395\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t\n\t\t<div class=\"p20644974 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-text piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-patient_name piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-patient_name\" class=\"piotnetforms-field-label\">Nom du patient<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><input size=\"1\" class=\"piotnetforms-field piotnetforms-size-\" type=\"text\" name=\"form_fields[patient_name]\" id=\"form-field-patient_name\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-section p83994651\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p83151364\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t\n\t\t<div class=\"p77504831 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-radio piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-for_child piotnetforms-col-100\">\n\t\t\t\t<label for=\"form-field-for_child\" class=\"piotnetforms-field-label\">Ce patient est-il un enfant?<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><script type=\"text\/javascript\">if(void 0===clearValidity)function clearValidity(i){jQuery(i).closest(\".piotnetforms-field-subgroup\").find(\".piotnetforms-field-option input\").each((function(){jQuery(this)[0].setCustomValidity(\"\")}))}<\/script><div class=\"piotnetforms-field-subgroup piotnetforms-field-subgroup--native  piotnetforms-field-subgroup--checkbox-replacement piotnetforms-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"No\" data-value=\"No\" id=\"form-field-for_child-0\" name=\"form_fields[for_child]\" data-piotnetforms-default-value=\"No\" checked=\"checked checked\" data-checked=\"checked checked\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-for_child-0\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Non<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Yes\" data-value=\"Yes\" id=\"form-field-for_child-1\" name=\"form_fields[for_child]\" data-piotnetforms-default-value=\"No\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-for_child-1\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Oui<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-column p66155407\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t\n\t\t<div class=\"p70877023 piotnetforms-fields-wrapper piotnetforms-labels-above\" style=\"display:none;\">\n\t\t\t<div class=\"piotnetforms-field-type-text piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-guardian piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\" data-piotnetforms-conditional-logic=\"[{&quot;piotnetforms_conditional_logic_form_action&quot;:[&quot;show&quot;],&quot;piotnetforms_conditional_logic_form_comparison_operators&quot;:&quot;=&quot;,&quot;piotnetforms_conditional_logic_form_type&quot;:&quot;string&quot;,&quot;piotnetforms_conditional_logic_form_and_or_operators&quot;:&quot;or&quot;,&quot;repeater_item_title&quot;:&quot;{{{ piotnetforms_conditional_logic_form_if }}} {{{ piotnetforms_conditional_logic_form_comparison_operators }}} {{{ piotnetforms_conditional_logic_form_value }}}&quot;,&quot;repeater_id&quot;:&quot;p60636166&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;for_child&quot;,&quot;piotnetforms_conditional_logic_form_value&quot;:&quot;Yes&quot;}]\" data-piotnetforms-conditional-logic-speed=\"400\" data-piotnetforms-conditional-logic-easing=\"swing\">\n\t\t\t\t<label for=\"form-field-guardian\" class=\"piotnetforms-field-label\">Parent\/Gardien<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><input size=\"1\" class=\"piotnetforms-field piotnetforms-size-\" type=\"text\" name=\"form_fields[guardian]\" id=\"form-field-guardian\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-section p39349379\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p84409988\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t\n\t\t<div class=\"p75737842 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-date piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-patient_bday piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-patient_bday\" class=\"piotnetforms-field-label\">Date de naissance<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><input class=\"piotnetforms-field piotnetforms-size- piotnetforms-field-textual piotnetforms-date-field\" type=\"date\" name=\"form_fields[patient_bday]\" id=\"form-field-patient_bday\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\" data-piotnetforms-date-calculate=\"\" data-date-format=\"F j, Y\" data-piotnetforms-date-language=\"english\"><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-column p92156256\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t\n\t\t<div class=\"p67413487 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-text piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-patient_phone piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-patient_phone\" class=\"piotnetforms-field-label\">Num\u00e9ro de t\u00e9l\u00e9phone<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><input size=\"1\" class=\"piotnetforms-field piotnetforms-size-\" type=\"text\" name=\"form_fields[patient_phone]\" id=\"form-field-patient_phone\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div>\t\t\n\t\t<div class=\"p67369173 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-textarea piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-patient_address piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-patient_address\" class=\"piotnetforms-field-label\">Adresse<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><textarea class=\"piotnetforms-field-textual piotnetforms-field piotnetforms-size-\" name=\"form_fields[patient_address]\" id=\"form-field-patient_address\" rows=\"3\" required=\"required\" aria-required=\"true\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"><\/textarea><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\n\t\t<div class=\"p57206028 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-radio piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-insurance piotnetforms-col-100\">\n\t\t\t\t<label for=\"form-field-insurance\" class=\"piotnetforms-field-label\">Svp s\u00e9lectionnez un<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><script type=\"text\/javascript\">if(void 0===clearValidity)function clearValidity(i){jQuery(i).closest(\".piotnetforms-field-subgroup\").find(\".piotnetforms-field-option input\").each((function(){jQuery(this)[0].setCustomValidity(\"\")}))}<\/script><div class=\"piotnetforms-field-subgroup piotnetforms-field-subgroup--native  piotnetforms-field-subgroup--checkbox-replacement piotnetforms-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Dental Insurance\" data-value=\"Dental Insurance\" id=\"form-field-insurance-0\" name=\"form_fields[insurance]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-insurance-0\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Assurance dentaire<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Indian Affairs\" data-value=\"Indian Affairs\" id=\"form-field-insurance-1\" name=\"form_fields[insurance]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-insurance-1\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Affaires indiennes<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Social Assistance\" data-value=\"Social Assistance\" id=\"form-field-insurance-2\" name=\"form_fields[insurance]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-insurance-2\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Assistance sociale<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Not applicable\" data-value=\"Not applicable\" id=\"form-field-insurance-3\" name=\"form_fields[insurance]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-insurance-3\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>N\u2019est pas applicable<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\n\t\t<div class=\"p50017489 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-checkbox piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-treatment piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-treatment\" class=\"piotnetforms-field-label\">Type de traitement :<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><script type=\"text\/javascript\">if(void 0===clearValidity)function clearValidity(i){jQuery(i).closest(\".piotnetforms-field-subgroup\").find(\".piotnetforms-field-option input\").each((function(){jQuery(this)[0].setCustomValidity(\"\")}))}<\/script><div class=\"piotnetforms-field-subgroup piotnetforms-field-subgroup--native  piotnetforms-field-subgroup--checkbox-replacement piotnetforms-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\"Extraction\" data-value=\"Extraction\" id=\"form-field-treatment-0\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-0\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Extraction<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\"Exposure\" data-value=\"Exposure\" id=\"form-field-treatment-1\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-1\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Exposure<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\"TMJ\" data-value=\"TMJ\" id=\"form-field-treatment-2\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-2\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>ATM<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\"Apical Surgery\" data-value=\"Apical Surgery\" id=\"form-field-treatment-3\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-3\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Apectomie<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\"Pathology\" data-value=\"Pathology\" id=\"form-field-treatment-4\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-4\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Pathologie<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\" Implantology\" data-value=\" Implantology\" id=\"form-field-treatment-5\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-5\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Implantologie<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\"Jaw Surgery\" data-value=\"Jaw Surgery\" id=\"form-field-treatment-6\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-6\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Orthognatique<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"checkbox\" value=\"Pre-prosthetic Surgery\" data-value=\"Pre-prosthetic Surgery\" id=\"form-field-treatment-7\" name=\"form_fields[treatment][]\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-treatment-7\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Chirurgie pr\u00e9-proth\u00e9tique<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\n\t\t<div class=\"p94956324 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-radio piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-p71210789 piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-p71210789\" class=\"piotnetforms-field-label\">Inclure les d\u00e9tails de la cartographie des dents ?<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><script type=\"text\/javascript\">if(void 0===clearValidity)function clearValidity(i){jQuery(i).closest(\".piotnetforms-field-subgroup\").find(\".piotnetforms-field-option input\").each((function(){jQuery(this)[0].setCustomValidity(\"\")}))}<\/script><div class=\"piotnetforms-field-subgroup piotnetforms-field-subgroup--native  piotnetforms-field-subgroup--checkbox-replacement piotnetforms-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Yes\" data-value=\"Yes\" id=\"form-field-p71210789-0\" name=\"form_fields[p71210789]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-p71210789-0\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Oui<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"No\" data-value=\"No\" id=\"form-field-p71210789-1\" name=\"form_fields[p71210789]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-p71210789-1\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Non<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\n\t\t<div class=\"p84362499 piotnetforms-fields-wrapper piotnetforms-labels-above\" style=\"display:none;\">\n\t\t\t<div class=\"piotnetforms-field-type-radio piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-p61867646 piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\" data-piotnetforms-conditional-logic=\"[{&quot;piotnetforms_conditional_logic_form_action&quot;:[&quot;show&quot;],&quot;piotnetforms_conditional_logic_form_comparison_operators&quot;:&quot;=&quot;,&quot;piotnetforms_conditional_logic_form_type&quot;:&quot;string&quot;,&quot;piotnetforms_conditional_logic_form_and_or_operators&quot;:&quot;or&quot;,&quot;repeater_item_title&quot;:&quot;{{{ piotnetforms_conditional_logic_form_if }}} {{{ piotnetforms_conditional_logic_form_comparison_operators }}} {{{ piotnetforms_conditional_logic_form_value }}}&quot;,&quot;repeater_id&quot;:&quot;p47747967&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;p71210789&quot;,&quot;piotnetforms_conditional_logic_form_value&quot;:&quot;Yes&quot;}]\" data-piotnetforms-conditional-logic-speed=\"400\" data-piotnetforms-conditional-logic-easing=\"swing\">\n\t\t\t\t<label for=\"form-field-p61867646\" class=\"piotnetforms-field-label\">Graphique<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><script type=\"text\/javascript\">if(void 0===clearValidity)function clearValidity(i){jQuery(i).closest(\".piotnetforms-field-subgroup\").find(\".piotnetforms-field-option input\").each((function(){jQuery(this)[0].setCustomValidity(\"\")}))}<\/script><div class=\"piotnetforms-field-subgroup piotnetforms-field-subgroup--native  piotnetforms-field-subgroup--checkbox-replacement piotnetforms-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Child\" data-value=\"Child\" id=\"form-field-p61867646-0\" name=\"form_fields[p61867646]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-p61867646-0\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Enfant<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Adult\" data-value=\"Adult\" id=\"form-field-p61867646-1\" name=\"form_fields[p61867646]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-p61867646-1\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Adulte<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<p class=\"p2111832\" data-piotnetforms-conditional-logic=\"[{&quot;piotnetforms_conditional_logic_form_comparison_operators&quot;:&quot;=&quot;,&quot;piotnetforms_conditional_logic_form_type&quot;:&quot;string&quot;,&quot;piotnetforms_conditional_logic_form_value&quot;:&quot;Child&quot;,&quot;piotnetforms_conditional_logic_form_and_or_operators&quot;:&quot;or&quot;,&quot;repeater_id&quot;:&quot;p65762177&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;[field id=\\&quot;p61867646\\&quot;]&quot;}]\" data-piotnetforms-conditional-logic-not-field=\"\" data-piotnetforms-conditional-logic-not-field-form-id=\"6352\" data-piotnetforms-conditional-logic-speed=\"400\" data-piotnetforms-conditional-logic-easing=\"swing\">Sch\u00e9ma des dents pour enfants<\/p>\t\t\n\t\t<div class=\"p28609388 piotnetforms-fields-wrapper piotnetforms-labels-above\" style=\"display:none;\">\n\t\t\t<div class=\"piotnetforms-field-type-image_select piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-youth_chart piotnetforms-col-100 piotnetforms-field-type-image_select-multiple\" data-piotnetforms-conditional-logic=\"[{&quot;piotnetforms_conditional_logic_form_action&quot;:[&quot;show&quot;],&quot;piotnetforms_conditional_logic_form_comparison_operators&quot;:&quot;=&quot;,&quot;piotnetforms_conditional_logic_form_type&quot;:&quot;string&quot;,&quot;piotnetforms_conditional_logic_form_and_or_operators&quot;:&quot;or&quot;,&quot;repeater_item_title&quot;:&quot;{{{ piotnetforms_conditional_logic_form_if }}} {{{ piotnetforms_conditional_logic_form_comparison_operators }}} {{{ piotnetforms_conditional_logic_form_value }}}&quot;,&quot;repeater_id&quot;:&quot;p67265111&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;p61867646&quot;,&quot;piotnetforms_conditional_logic_form_value&quot;:&quot;Child&quot;}]\" data-piotnetforms-conditional-logic-speed=\"400\" data-piotnetforms-conditional-logic-easing=\"swing\">\n\t\t\t\t<label style=\"display:none\" for=\"form-field-youth_chart\" class=\"piotnetforms-field-label\">Sch\u00e9ma des dents pour enfants<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><div data-piotnetforms-image_select_min_select_check><\/div>\t\t<div class=\"piotnetforms-field piotnetforms-select-wrapper piotnetforms-select-multiple\">\n\t\t\t<select name=\"form_fields[youth_chart][]\" id=\"form-field-youth_chart\" class=\"piotnetforms-field-textual piotnetforms-size-\" data-piotnetforms-type=\"select\" data-piotnetforms-image-select=\"[{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2022\\\/11\\\/checkbox-new.png&quot;}]\" multiple=\"\" size=\"2\" data-piotnetforms-send-data-by-label=\"\" data-piotnetforms-id=\"6352\" data-piotnetforms-default-value=\" \" data-options='[\"55\",\"54\",\"53\",\"52\",\"51\",\"61\",\"62\",\"63\",\"64\",\"65\",\"85\",\"84\",\"83\",\"82\",\"81\",\"71\",\"72\",\"73\",\"74\",\"75\"]'>\n\t\t\t\t<option value=\"55\" data-piotnetforms-send-data-by-label=\"55\">55<\/option><option value=\"54\" data-piotnetforms-send-data-by-label=\"54\">54<\/option><option value=\"53\" data-piotnetforms-send-data-by-label=\"53\">53<\/option><option value=\"52\" data-piotnetforms-send-data-by-label=\"52\">52<\/option><option value=\"51\" data-piotnetforms-send-data-by-label=\"51\">51<\/option><option value=\"61\" data-piotnetforms-send-data-by-label=\"61\">61<\/option><option value=\"62\" data-piotnetforms-send-data-by-label=\"62\">62<\/option><option value=\"63\" data-piotnetforms-send-data-by-label=\"63\">63<\/option><option value=\"64\" data-piotnetforms-send-data-by-label=\"64\">64<\/option><option value=\"65\" data-piotnetforms-send-data-by-label=\"65\">65<\/option><option value=\"85\" data-piotnetforms-send-data-by-label=\"85\">85<\/option><option value=\"84\" data-piotnetforms-send-data-by-label=\"84\">84<\/option><option value=\"83\" data-piotnetforms-send-data-by-label=\"83\">83<\/option><option value=\"82\" data-piotnetforms-send-data-by-label=\"82\">82<\/option><option value=\"81\" data-piotnetforms-send-data-by-label=\"81\">81<\/option><option value=\"71\" data-piotnetforms-send-data-by-label=\"71\">71<\/option><option value=\"72\" data-piotnetforms-send-data-by-label=\"72\">72<\/option><option value=\"73\" data-piotnetforms-send-data-by-label=\"73\">73<\/option><option value=\"74\" data-piotnetforms-send-data-by-label=\"74\">74<\/option><option value=\"75\" data-piotnetforms-send-data-by-label=\"75\">75<\/option>\t\t\t<\/select>\n\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<p class=\"p27132813\" data-piotnetforms-conditional-logic=\"[{&quot;piotnetforms_conditional_logic_form_comparison_operators&quot;:&quot;=&quot;,&quot;piotnetforms_conditional_logic_form_type&quot;:&quot;string&quot;,&quot;piotnetforms_conditional_logic_form_value&quot;:&quot;Adult&quot;,&quot;piotnetforms_conditional_logic_form_and_or_operators&quot;:&quot;or&quot;,&quot;repeater_id&quot;:&quot;p67884866&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;[field id=\\&quot;p61867646\\&quot;]&quot;}]\" data-piotnetforms-conditional-logic-not-field=\"\" data-piotnetforms-conditional-logic-not-field-form-id=\"6352\" data-piotnetforms-conditional-logic-speed=\"400\" data-piotnetforms-conditional-logic-easing=\"swing\">Sch\u00e9ma des dents adultes<\/p>\t\t\n\t\t<div class=\"p75341562 piotnetforms-fields-wrapper piotnetforms-labels-above\" style=\"display:none;\">\n\t\t\t<div class=\"piotnetforms-field-type-image_select piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-adult_chart piotnetforms-col-100 piotnetforms-field-type-image_select-multiple\" data-piotnetforms-conditional-logic=\"[{&quot;piotnetforms_conditional_logic_form_action&quot;:[&quot;show&quot;],&quot;piotnetforms_conditional_logic_form_comparison_operators&quot;:&quot;=&quot;,&quot;piotnetforms_conditional_logic_form_type&quot;:&quot;string&quot;,&quot;piotnetforms_conditional_logic_form_and_or_operators&quot;:&quot;or&quot;,&quot;repeater_item_title&quot;:&quot;{{{ piotnetforms_conditional_logic_form_if }}} {{{ piotnetforms_conditional_logic_form_comparison_operators }}} {{{ piotnetforms_conditional_logic_form_value }}}&quot;,&quot;repeater_id&quot;:&quot;p67845691&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;p61867646&quot;,&quot;piotnetforms_conditional_logic_form_value&quot;:&quot;Adult&quot;}]\" data-piotnetforms-conditional-logic-speed=\"400\" data-piotnetforms-conditional-logic-easing=\"swing\">\n\t\t\t\t<label style=\"display:none\" for=\"form-field-adult_chart\" class=\"piotnetforms-field-label\">Sch\u00e9ma des dents adultes<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><div data-piotnetforms-image_select_min_select_check><\/div>\t\t<div class=\"piotnetforms-field piotnetforms-select-wrapper piotnetforms-select-multiple\">\n\t\t\t<select name=\"form_fields[adult_chart][]\" id=\"form-field-adult_chart\" class=\"piotnetforms-field-textual piotnetforms-size-\" data-piotnetforms-type=\"select\" 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multiple=\"\" size=\"2\" data-piotnetforms-send-data-by-label=\"\" data-piotnetforms-id=\"6352\" data-piotnetforms-default-value=\" \" data-options='[\"18\",\"17\",\"16\",\"15\",\"14\",\"13\",\"12\",\"11\",\"21\",\"22\",\"23\",\"24\",\"25\",\"26\",\"27\",\"28\",\"48\",\"47\",\"46\",\"45\",\"44\",\"43\",\"42\",\"41\",\"31\",\"32\",\"33\",\"34\",\"35\",\"36\",\"37\",\"38\"]'>\n\t\t\t\t<option value=\"18\" data-piotnetforms-send-data-by-label=\"18\">18<\/option><option value=\"17\" data-piotnetforms-send-data-by-label=\"17\">17<\/option><option value=\"16\" data-piotnetforms-send-data-by-label=\"16\">16<\/option><option value=\"15\" data-piotnetforms-send-data-by-label=\"15\">15<\/option><option value=\"14\" data-piotnetforms-send-data-by-label=\"14\">14<\/option><option value=\"13\" data-piotnetforms-send-data-by-label=\"13\">13<\/option><option value=\"12\" data-piotnetforms-send-data-by-label=\"12\">12<\/option><option value=\"11\" data-piotnetforms-send-data-by-label=\"11\">11<\/option><option value=\"21\" data-piotnetforms-send-data-by-label=\"21\">21<\/option><option value=\"22\" data-piotnetforms-send-data-by-label=\"22\">22<\/option><option value=\"23\" data-piotnetforms-send-data-by-label=\"23\">23<\/option><option value=\"24\" data-piotnetforms-send-data-by-label=\"24\">24<\/option><option value=\"25\" data-piotnetforms-send-data-by-label=\"25\">25<\/option><option value=\"26\" data-piotnetforms-send-data-by-label=\"26\">26<\/option><option value=\"27\" data-piotnetforms-send-data-by-label=\"27\">27<\/option><option value=\"28\" data-piotnetforms-send-data-by-label=\"28\">28<\/option><option value=\"48\" data-piotnetforms-send-data-by-label=\"48\">48<\/option><option value=\"47\" data-piotnetforms-send-data-by-label=\"47\">47<\/option><option value=\"46\" data-piotnetforms-send-data-by-label=\"46\">46<\/option><option value=\"45\" data-piotnetforms-send-data-by-label=\"45\">45<\/option><option value=\"44\" 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class=\"p62420106 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-radio piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-xray_request piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-xray_request\" class=\"piotnetforms-field-label\">X-Rays request :<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><script type=\"text\/javascript\">if(void 0===clearValidity)function clearValidity(i){jQuery(i).closest(\".piotnetforms-field-subgroup\").find(\".piotnetforms-field-option input\").each((function(){jQuery(this)[0].setCustomValidity(\"\")}))}<\/script><div class=\"piotnetforms-field-subgroup piotnetforms-field-subgroup--native  piotnetforms-field-subgroup--checkbox-replacement piotnetforms-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"X-Ray Included\" data-value=\"X-Ray Included\" id=\"form-field-xray_request-0\" name=\"form_fields[xray_request]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-xray_request-0\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Radiographie attach\u00e9e<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"X-Ray Emailed\" data-value=\"X-Ray Emailed\" id=\"form-field-xray_request-1\" name=\"form_fields[xray_request]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-xray_request-1\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Radiographie envoy\u00e9 par courriel<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Please Take X-Ray\" data-value=\"Please Take X-Ray\" id=\"form-field-xray_request-2\" name=\"form_fields[xray_request]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"> <label for=\"form-field-xray_request-2\" class=\"\"><span class=\"pf-f-o-i pf-f-o-i-has-checked\"><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--normal fal fa-square\"><\/i><i class=\"pf-f-o-i-font-awesome pf-f-o-i-font-awesome--checked far fa-check-square\"><\/i><\/span>Svp prenez une radiographie<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\n\t\t<div class=\"p81199528 piotnetforms-fields-wrapper piotnetforms-labels-above\" style=\"display:none;\">\n\t\t\t<div class=\"piotnetforms-field-type-upload 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margin-top:10px;font-size:14px; line-height:18px;\">You can upload JPEG, PNG, or PDF files. 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id=\"form-field-dentist_email\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6352\"><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div>\t\t\n\t\t<div class=\"p53140454 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-textarea piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-remarks piotnetforms-col-100\">\n\t\t\t\t<label for=\"form-field-remarks\" class=\"piotnetforms-field-label\">Remarques<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><textarea class=\"piotnetforms-field-textual piotnetforms-field piotnetforms-size-\" name=\"form_fields[remarks]\" id=\"form-field-remarks\" rows=\"3\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6352\"><\/textarea><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<p class=\"p12712959\">Si vous avez besoin d\u2019une 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