{"id":4115,"date":"2018-04-30T22:19:50","date_gmt":"2018-05-01T01:19:50","guid":{"rendered":"https:\/\/ecos.panchroma.dev?page_id=4115"},"modified":"2024-07-02T09:51:57","modified_gmt":"2024-07-02T12:51:57","slug":"formulaire-de-reference","status":"publish","type":"page","link":"https:\/\/eastcoastoralsurgery.ca\/fr\/formulaire-de-reference","title":{"rendered":"Formulaire de r\u00e9f\u00e9rence"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling do-not-print\" 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-margin-top:40px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1244.88px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_3 1_3 fusion-flex-column fusion-no-small-visibility\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><p><img decoding=\"async\" class=\"alignnone size-medium wp-image-3844 aligncenter\" style=\"padding-top: 20px;\" src=\"https:\/\/eastcoastoralsurgery.ca\/wp-content\/uploads\/2017\/11\/ecos-logo-1-300x132.png\" alt=\"\" width=\"300\" height=\"132\" srcset=\"https:\/\/eastcoastoralsurgery.ca\/wp-content\/uploads\/2017\/11\/ecos-logo-1-200x88.png 200w, https:\/\/eastcoastoralsurgery.ca\/wp-content\/uploads\/2017\/11\/ecos-logo-1-300x132.png 300w, https:\/\/eastcoastoralsurgery.ca\/wp-content\/uploads\/2017\/11\/ecos-logo-1.png 333w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_2_3 2_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:66.666666666667%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.88%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:2.88%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2\"><p><strong>Chirurgie buccale de la c\u00f4te Est<\/strong><br \/>\n585 chemin Mapleton, bureau 301<br \/>\nMoncton, Nouveau-Brunswick.\u00a0 E1G 2K5<br \/>\nT: 506-859-7200<br \/>\nF: 506-854-4828<\/p>\n<\/div><style>\n.print-only{\n  display:none;\n}\n@media print{\n.do-not-print,\n  .fusion-tb-header,\n  .fusion-footer,\n  .avada-page-titlebar-wrapper{\n    display:none;}\n    .print-only{\n      display:block;\n  }\n  section#content {\n    width: 100% !important;\n}\n}\n<\/style><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container 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-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1244.88px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-3 fusion-text-no-margin print-only\" style=\"--awb-margin-bottom:0px;\"><p><strong>Formulaire de r\u00e9f\u00e9rence : <\/strong>Chirurgie buccale de la c\u00f4te Est<br \/>\n585 chemin Mapleton, bureau 301, Moncton, Nouveau-Brunswick. E1G 2K5<\/p>\n<\/div><script>\n  jQuery(document).ready(function($){\n    window.onbeforeprint = function () {\n      $('.print-content').remove();\n      $('textarea').each(function () {\n        var text = $(this).val();\n        $(this).after('<p class=\"well print-content\">' + text + '<\/p>');\n      });\n    }\n    \n    $('#print-form').on('click', function(e) {\n      e.preventDefault();\n      window.print();\n    });\n  });\n<\/script><div id=\"piotnetforms\" class=\"piotnetforms piotnetforms-6651\" data-piotnetforms-shortcode-id=\"6651\"><form id=\"6651\" class=\"piotnetforms__form\" onsubmit=\"return false\"><div class=\"piotnet-section p44762895\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p27428650\">\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=\"p9502646 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\"><div class=\"piotnetforms-field-icon\"><\/div><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-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Dr. Nach Daniel\" data-value=\"Dr. Nach Daniel\" id=\"form-field-doctor-0\" name=\"form_fields[doctor]\" data-piotnetforms-default-value=\"Pas de pr\u00e9f\u00e9rence\" data-piotnetforms-send-data-by-label=\"Dr. Nach 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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=\"6651\"><\/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 p22194922\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p95896768\">\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=\"p64751364 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=\"6651\" max=\"2026-06-04\" data-piotnetforms-date-calculate=\"\" data-date-format=\"F j, Y\" data-piotnetforms-date-language=\"fr\"><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-column p4745140\">\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=\"p37964468 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=\"6651\"><\/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=\"p76478127 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=\"6651\"><\/textarea><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\n\t\t<div class=\"p4393196 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\">Assurance<\/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-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=\"6651\"> <label for=\"form-field-insurance-0\" class=\"\">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=\"6651\"> <label for=\"form-field-insurance-1\" class=\"\">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=\"6651\"> <label for=\"form-field-insurance-2\" class=\"\">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=\"6651\"> <label for=\"form-field-insurance-3\" class=\"\">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=\"p72818334 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-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=\"6651\"> <label for=\"form-field-treatment-0\" class=\"\">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=\"6651\"> <label for=\"form-field-treatment-1\" class=\"\">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=\"6651\"> <label for=\"form-field-treatment-2\" class=\"\">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=\"6651\"> <label for=\"form-field-treatment-3\" class=\"\">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=\"6651\"> <label for=\"form-field-treatment-4\" class=\"\">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=\"6651\"> <label for=\"form-field-treatment-5\" class=\"\">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=\"6651\"> <label for=\"form-field-treatment-6\" class=\"\">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=\"6651\"> <label for=\"form-field-treatment-7\" class=\"\">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=\"p96934933 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-radio piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-include_chart piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-include_chart\" 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-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Yes\" data-value=\"Yes\" id=\"form-field-include_chart-0\" name=\"form_fields[include_chart]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6651\"> <label for=\"form-field-include_chart-0\" class=\"\">Oui<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"No\" data-value=\"No\" id=\"form-field-include_chart-1\" name=\"form_fields[include_chart]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6651\"> <label for=\"form-field-include_chart-1\" class=\"\">Non<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\n\t\t<div class=\"p54008932 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-chart_type 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;include_chart&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-chart_type\" class=\"piotnetforms-field-label\">Graphique<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><div class=\"piotnetforms-field-icon\"><\/div><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-subgroup-inline\"><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Child\" data-value=\"Child\" id=\"form-field-chart_type-0\" name=\"form_fields[chart_type]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6651\"> <label for=\"form-field-chart_type-0\" class=\"\">Enfant<\/label><\/span><span class=\"piotnetforms-field-option\"><input type=\"radio\" value=\"Adult\" data-value=\"Adult\" id=\"form-field-chart_type-1\" name=\"form_fields[chart_type]\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6651\"> <label for=\"form-field-chart_type-1\" class=\"\">Adulte<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<p class=\"p80779626\" 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;chart_type\\&quot;]&quot;}]\" data-piotnetforms-conditional-logic-not-field=\"\" data-piotnetforms-conditional-logic-not-field-form-id=\"6651\" 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=\"p70957763 teeth_chart 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 piotnetforms-field-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;p67265111&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;chart_type&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;6664&quot;,&quot;url&quot;:&quot;https:\\\/\\\/ecos.panchroma.dev\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;6664&quot;,&quot;url&quot;:&quot;https:\\\/\\\/ecos.panchroma.dev\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;6664&quot;,&quot;url&quot;:&quot;https:\\\/\\\/ecos.panchroma.dev\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;6664&quot;,&quot;url&quot;:&quot;https:\\\/\\\/ecos.panchroma.dev\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;}]\" required=\"required\" aria-required=\"true\" multiple=\"\" size=\"2\" data-piotnetforms-send-data-by-label=\"\" data-piotnetforms-id=\"6651\" 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=\"p75343792\" 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;chart_type\\&quot;]&quot;}]\" data-piotnetforms-conditional-logic-not-field=\"\" data-piotnetforms-conditional-logic-not-field-form-id=\"6651\" 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=\"p40690671 teeth_chart 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 piotnetforms-field-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;p67845691&quot;,&quot;piotnetforms_conditional_logic_form_if&quot;:&quot;chart_type&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\" data-piotnetforms-image-select=\"[{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;},{&quot;id&quot;:&quot;741&quot;,&quot;url&quot;:&quot;\\\/wp-content\\\/uploads\\\/2023\\\/10\\\/checkbox-chart.png&quot;}]\" required=\"required\" aria-required=\"true\" multiple=\"\" size=\"2\" data-piotnetforms-send-data-by-label=\"\" data-piotnetforms-id=\"6651\" 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\" data-piotnetforms-send-data-by-label=\"44\">44<\/option><option value=\"43\" data-piotnetforms-send-data-by-label=\"43\">43<\/option><option value=\"42\" data-piotnetforms-send-data-by-label=\"42\">42<\/option><option value=\"41\" data-piotnetforms-send-data-by-label=\"41\">41<\/option><option value=\"31\" data-piotnetforms-send-data-by-label=\"31\">31<\/option><option value=\"32\" data-piotnetforms-send-data-by-label=\"32\">32<\/option><option value=\"33\" data-piotnetforms-send-data-by-label=\"33\">33<\/option><option value=\"34\" data-piotnetforms-send-data-by-label=\"34\">34<\/option><option value=\"35\" data-piotnetforms-send-data-by-label=\"35\">35<\/option><option value=\"36\" data-piotnetforms-send-data-by-label=\"36\">36<\/option><option value=\"37\" data-piotnetforms-send-data-by-label=\"37\">37<\/option><option value=\"38\" data-piotnetforms-send-data-by-label=\"38\">38<\/option>\t\t\t<\/select>\n\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<style>#piotnetforms ul.thumbnails.image_picker_selector li .thumbnail {\n    padding: 0;\n    border: none !important;\n }<\/style>\t\t\n\t\t<div class=\"p48080625 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\">Demande de radiographies:<\/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-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=\"6651\"> <label for=\"form-field-xray_request-0\" class=\"\">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=\"6651\"> <label for=\"form-field-xray_request-1\" class=\"\">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=\"6651\"> <label for=\"form-field-xray_request-2\" class=\"\">SVP prenez une radiographie<\/label><\/span><\/div><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<div class=\"piotnet-section p96538595\" data-piotnetforms-repeater-form-id=\"6651\" data-piotnetforms-repeater-id=\"upload_repeater_1\" data-piotnetforms-repeater-label=\"XRay Upload\" data-piotnetforms-repeater-limit=\"\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p94300582\">\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=\"p62604893 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-upload piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-xray piotnetforms-col-100\">\n\t\t\t\t<label for=\"form-field-xray\" class=\"piotnetforms-field-label\">Radiographie<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><input type=\"file\" class=\"piotnetforms-field piotnetforms-size-\" type=\"upload\" name=\"upload_field\" id=\"form-field-xray\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" data-attach-files=\"\" data-maxsize=\"5\" data-maxsize-message=\"File size must be less than 5MB\" data-accept=\"jpg,png,jpeg,pdf\" data-types-message=\"Allowed file types: JPEG, PNG, PDF\" data-piotnetforms-id=\"6651\"><div class=\"piotnetforms-upload-preview\"><\/div><\/div><div class=\"piotnetforms-field-description\"> <span style=\"display:inline-block; margin-top:10px;font-size:14px; line-height:18px;\">Vous pouvez t\u00e9l\u00e9charger des fichiers JPEG, PNG ou PDF. Max. la taille est de 5 MB.<\/span><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-column p51670897\">\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=\"p58630444 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-date piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-xray_date piotnetforms-col-100\">\n\t\t\t\t<label for=\"form-field-xray_date\" class=\"piotnetforms-field-label\">Date<\/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[xray_date]\" id=\"form-field-xray_date\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6651\" 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 p65393786\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t<div class=\"p35517206 piotnetforms-icon\" data-piotnetforms-repeater-form-id-trigger=\"6651\" data-piotnetforms-repeater-id-trigger=\"upload_repeater_1\" data-piotnetforms-repeater-trigger-action=\"remove\">\n\t\t\t\t\t\t<div class=\"piotnetforms-icon__item default-circle\"><i class=\"fas fa-window-close\"><\/i><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-section p92294904\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p90061016\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t<p class=\"p31881515\">T\u00e9l\u00e9charger une autre radiographie<\/p>\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-column p99649069\">\t\t\t\t\t\t<div class=\"piotnet-column__inner\"\n\t\t\t>\n\t\t\t\t<div class=\"p34992281 piotnetforms-icon\" data-piotnetforms-repeater-form-id-trigger=\"6651\" data-piotnetforms-repeater-id-trigger=\"upload_repeater_1\" data-piotnetforms-repeater-trigger-action=\"add\">\n\t\t\t\t\t\t<div class=\"piotnetforms-icon__item default-circle\"><i class=\"fas fa-plus-square\"><\/i><\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-section p97339433\">\t\t\t\t\t\t<div class=\"piotnet-section__container\"\n\t\t>\n\t\t<div class=\"piotnet-column p32785714\">\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=\"p68069706 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-text piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-referring_dentist piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-referring_dentist\" class=\"piotnetforms-field-label\">Dentiste r\u00e9f\u00e9rant:<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><input size=\"1\" class=\"piotnetforms-field piotnetforms-size-\" type=\"text\" name=\"form_fields[referring_dentist]\" id=\"form-field-referring_dentist\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6651\"><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div><div class=\"piotnet-column p55655188\">\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=\"p31824977 piotnetforms-fields-wrapper piotnetforms-labels-above\">\n\t\t\t<div class=\"piotnetforms-field-type-email piotnetforms-field-group piotnetforms-column  piotnetforms-field-group-dentist_email piotnetforms-col-100 piotnetforms-field-required piotnetforms-mark-required\">\n\t\t\t\t<label for=\"form-field-dentist_email\" class=\"piotnetforms-field-label\">Courriel de bureau:<\/label><div data-piotnetforms-required><\/div><div class=\"piotnetforms-field-container\"><input size=\"1\" class=\"piotnetforms-field piotnetforms-size-\" type=\"email\" name=\"form_fields[dentist_email]\" id=\"form-field-dentist_email\" autocomplete=\"on\" data-piotnetforms-default-value=\"\" required=\"required\" aria-required=\"true\" data-piotnetforms-id=\"6651\"><\/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=\"p29898431 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=\"5\" data-piotnetforms-default-value=\"\" data-piotnetforms-id=\"6651\"><\/textarea><\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t<p class=\"p43074394\">Si vous avez besoin d\u2019une copie pour vos fili\u00e8res, svp cliquer le bouton imprim\u00e9<\/p>\t\t<div class=\"p19619388 piotnetforms-btn\" id=\"print-form\">\n\t\t\t\t\t\t\t<a class=\"piotnet-button\" href=\"#\" target=\"_self\">Imprimez cette page<\/a>\n\t\t\t\t\t<\/div>\t\n\t\t\t\t\t<\/div>\n\t\t<\/div>\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"p27983888 piotnetforms-submit piotnetforms-button-wrapper\">\n\n\t\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"6651\" data-piotnetforms-hidden-form-id=\"6651\"\/>\n\t\t<input type=\"hidden\" name=\"form_id\" value=\"p27983888\" data-piotnetforms-hidden-form-id=\"6651\"\/>\n\t\t<input type=\"hidden\" name=\"remote_ip\" value=\"216.73.216.217, 216.73.216.217\" data-piotnetforms-hidden-form-id=\"6651\"\/>\n\n\t\t\n\t\t\n\t\t\n\t\t\n\t\t<button class=\"piotnetforms-button-submit piotnetforms-button\" type=\"submit\" role=\"button\" data-piotnetforms-required-text=\"This field is required.\" data-piotnetforms-submit-form-id=\"6651\" data-piotnetforms-submit-keyboard=\"false\" data-piotnetforms-submit-hide=\"false\">\n\t\t\t\t\t<span class=\"piotnetforms-button-content-wrapper\">\n\t\t\t<span class=\"piotnetforms-button-text piotnetforms-spinner\"><span class=\"icon-spinner-of-dots\"><\/span><\/span>\n\t\t\t\t\t\t<span class=\"piotnetforms-button-text\">Envoyer<\/span>\n\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\n\t\t        \t\t        \t\t\n\t\t\n\t\t\n        \n            \t\t<div id=\"piotnetforms-trigger-success-6651\" data-piotnetforms-trigger-success=\"6651\" style=\"display: none\"><\/div>\n\t\t<div id=\"piotnetforms-trigger-failed-6651\" data-piotnetforms-trigger-failed=\"6651\" style=\"display: none\"><\/div>\n\t\t<div class=\"piotnetforms-alert piotnetforms-alert--mail\">\n\t\t\t<div class=\"piotnetforms-message piotnetforms-message-success\" role=\"alert\" data-piotnetforms-message=\"Votre r\u00e9f\u00e9rence a \u00e9t\u00e9 envoy\u00e9, merci !\">Votre r\u00e9f\u00e9rence a \u00e9t\u00e9 envoy\u00e9, merci !<\/div>\n\t\t\t<div class=\"piotnetforms-message piotnetforms-message-danger\" role=\"alert\" data-piotnetforms-message=\"An error occured.\">An error occured.<\/div>\n\t\t\t<!-- <div class=\"piotnetforms-message piotnetforms-help-inline\" role=\"alert\">Server error. 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