{"id":6218,"date":"2021-12-01T13:58:07","date_gmt":"2021-12-01T13:58:07","guid":{"rendered":"https:\/\/gentleproceduresnb.ca\/?page_id=6218"},"modified":"2021-12-01T13:59:22","modified_gmt":"2021-12-01T13:59:22","slug":"inscription-bebe","status":"publish","type":"page","link":"https:\/\/gentleproceduresnb.ca\/fr\/circoncision\/inscription-bebe\/","title":{"rendered":"Enregistrement &#8211; Circoncision pour b\u00e9b\u00e9"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6218\" class=\"elementor elementor-6218 elementor-54\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-169a61e elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"169a61e\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-140c138\" data-id=\"140c138\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6de07c7 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6de07c7\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-340aa03\" data-id=\"340aa03\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-a8a385e elementor-widget elementor-widget-heading\" data-id=\"a8a385e\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Enregistrement \u2013 Circoncision pour b\u00e9b\u00e9\n<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-54608b9 uael-button-halign-left uael-button-stack-none elementor-widget elementor-widget-uael-buttons\" data-id=\"54608b9\" data-element_type=\"widget\" data-widget_type=\"uael-buttons.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"uael-dual-button-outer-wrap\">\n\t\t\t<div class=\"uael-dual-button-wrap\">\n\t\t\t\t\t\t\t\t<div class=\"uael-button-wrapper uael-dual-button elementor-widget-button elementor-repeater-item-9871bb7 uael-dual-button-0\">\n\t\t\t\t\t<a class=\"elementor-button-link elementor-button elementor-size-md elementor-button-link\" href=\"\/fr\/contact\/\">\n\t\t\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper uael-buttons-icon-\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-align-icon- elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text elementor-inline-editing\" data-elementor-setting-key=\"buttons.0.text\" data-elementor-inline-editing-toolbar=\"none\">Contact<\/span>\n\t\t<\/span>\n\t\t\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-01fdb5f\" data-id=\"01fdb5f\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c3e659b elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c3e659b\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-wide\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-90296c9\" data-id=\"90296c9\" data-element_type=\"column\" id=\"page-form\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c7f6312 elementor-widget elementor-widget-text-editor\" data-id=\"c7f6312\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Veuillez compl\u00e9ter le formulaire d\u2019enregistrement pour planifier la circoncision de votre b\u00e9b\u00e9.<\/p><p>Nous vous rappellerons dans les plus brefs d\u00e9lais pour convenir d\u2019un rendez-vous et r\u00e9pondre \u00e0 vos questions.<\/p><p>Merci d\u2019utiliser nos services.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9950339 uael-gf-style-underline uael-gf-input-size-xs uael-gf-btn-size-xs uael-gf-button-center uael-gf-ajax-true uael-gf-enable-classes-no elementor-widget elementor-widget-uael-gf-styler\" data-id=\"9950339\" data-element_type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_22' ><form method='post' enctype='multipart\/form-data'  id='gform_22'  action='\/fr\/wp-json\/wp\/v2\/pages\/6218\/' data-formid='22' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_22' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_22_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Information de l&#039;enfant<\/h2><\/li><li id=\"field_22_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom du b\u00e9b\u00e9*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_1'>\n                            \n                            <span id='input_22_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_22_1_3' value='' tabindex='2'  aria-required='true'     \/>\n                                                    <label for='input_22_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_22_1_6' value='' tabindex='4'  aria-required='true'     \/>\n                                                    <label for='input_22_1_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_22_2\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_2'>Date de naissance*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_22_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='6'  placeholder='mm\/jj\/aaaa' aria-describedby=\"input_22_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_22_2_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_22_2' class='gform_hidden' value='https:\/\/gentleproceduresnb.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_22_64\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_64'>Num\u00e9ro de carte d&#039;assurance maladie<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_22_64' type='text' value='' class='medium'   tabindex='7' placeholder='si disponible'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_22_41\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Information des parents<\/h2><\/li><li id=\"field_22_43\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom du premier parent*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_43'>\n                            \n                            <span id='input_22_43_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.3' id='input_22_43_3' value='' tabindex='9'  aria-required='true'     \/>\n                                                    <label for='input_22_43_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_43_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_43.6' id='input_22_43_6' value='' tabindex='11'  aria-required='true'     \/>\n                                                    <label for='input_22_43_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_22_65\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_65'>Num\u00e9ro de carte d&#039;assurance maladie<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_22_65' type='text' value='' class='medium'   tabindex='13' placeholder='si disponible'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_22_42\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Nom du deuxi\u00e8me parent*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_42'>\n                            \n                            <span id='input_22_42_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.3' id='input_22_42_3' value='' tabindex='15'  aria-required='true'     \/>\n                                                    <label for='input_22_42_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_42_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_42.6' id='input_22_42_6' value='' tabindex='17'  aria-required='true'     \/>\n                                                    <label for='input_22_42_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_22_4\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Addresse*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_22_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_22_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_22_4_1' value='' tabindex='19'   aria-required='true'    \/>\n                                        <label for='input_22_4_1' id='input_22_4_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse civique<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_22_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_22_4_2' value='' tabindex='20'    aria-required='false'   \/>\n                                        <label for='input_22_4_2' id='input_22_4_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_22_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_22_4_3' value='' tabindex='21'   aria-required='true'    \/>\n                                    <label for='input_22_4_3' id='input_22_4_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_22_4_4_container' >\n                                        <select name='input_4.4' id='input_22_4_4' tabindex='22'    aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_22_4_4' id='input_22_4_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_22_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_22_4_5' value='' tabindex='24'   aria-required='true'    \/>\n                                    <label for='input_22_4_5' id='input_22_4_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_22_4_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_22_5\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_5'>T\u00e9l\u00e9phone pour vous rejoindre*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_22_5' type='tel' value='' class='medium' tabindex='25'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_22_6\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_6'>Adresse courriel*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_6' id='input_22_6' type='email' value='' class='medium' tabindex='26'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_22_63\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_63'>O\u00f9 avez vous entendu parler de nous?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_22_63' type='text' value='' class='medium'   tabindex='27'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_22_11\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Historique m\u00e9dical<\/h2><\/li><li id=\"field_22_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Votre b\u00e9b\u00e9 a-t-il eu des probl\u00e8mes m\u00e9dicaux ou des pertes de sang depuis sa naissance? Votre famille a-t-elle des historique de probl\u00e8mes de saignement? Avez-vous des raisons de croire que votre enfant a une pression art\u00e9rielle faible ou un faible taux d&#039;h\u00e9moglobine?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_22_13'>\n\t\t\t<li class='gchoice gchoice_22_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Oui'  id='choice_22_13_0' tabindex='28'   \/>\n\t\t\t\t<label for='choice_22_13_0' id='label_22_13_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_22_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Non'  id='choice_22_13_1' tabindex='29'   \/>\n\t\t\t\t<label for='choice_22_13_1' id='label_22_13_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_22_48\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_48'>Si oui, d\u00e9taillez:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_22_48' class='textarea medium' tabindex='30'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_22_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Y-a-t-il eu d&#039;importants probl\u00e8mes pour l&#039;enfant ou la m\u00e8re lorsque l&#039;enfant est n\u00e9?*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_22_17'>\n\t\t\t<li class='gchoice gchoice_22_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Oui'  id='choice_22_17_0' tabindex='31'   \/>\n\t\t\t\t<label for='choice_22_17_0' id='label_22_17_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_22_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='Non'  id='choice_22_17_1' tabindex='32'   \/>\n\t\t\t\t<label for='choice_22_17_1' id='label_22_17_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_22_23\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_23'>Si oui, d\u00e9taillez:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_22_23' class='textarea medium' tabindex='33'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_22_24\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_24'>Inscrivez toutes les m\u00e9dications prises par votre b\u00e9b\u00e9 pr\u00e9sentement (nom\/dosage).*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_22_24'>\u00c9crivez n\/a si aucun<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_22_24' class='textarea medium' tabindex='34' aria-describedby=\"gfield_description_22_24\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_22_61\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_61'>Si vous allaitez, inscrivez toutes les m\u00e9dications que vous prenez pr\u00e9sentement (nom\/dosage):*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_22_61'>\u00c9crivez n\/a si aucun.\n\nNotez que si la m\u00e8re prend sous quelque forme que ce soit des anticoagulants  (Dalteparin, ASA) vous aurez besoin d'appeler \u00e0 nos bureaux pour parler avec l'un de nos docteurs avant votre rendez-vous.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_22_61' class='textarea medium' tabindex='35' aria-describedby=\"gfield_description_22_61\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_22_25\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Information de contact<\/h2><div class='gsection_description' id='gfield_description_22_25'> <\/div><\/li><li id=\"field_22_27\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >M\u00e9decin de famille \/ P\u00e9diatre<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_27'>\n                            \n                            <span id='input_22_27_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.3' id='input_22_27_3' value='' tabindex='37'  aria-required='false'     \/>\n                                                    <label for='input_22_27_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_27_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.6' id='input_22_27_6' value='' tabindex='39'  aria-required='false'     \/>\n                                                    <label for='input_22_27_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_22_28\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_28'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_22_28' type='tel' value='' class='medium' tabindex='41'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_22_29\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Ville<\/label>    \n                    <div class='ginput_complex ginput_container has_city ginput_container_address gform-grid-row' id='input_22_29' >\n                        <span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_22_29_3_container' >\n                                    <input type='text' name='input_29.3' id='input_22_29_3' value='' tabindex='43'   aria-required='false'    \/>\n                                    <label for='input_22_29_3' id='input_22_29_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_29.4' id='input_22_29_4' value='Ontario'\/><input type='hidden' class='gform_hidden' name='input_29.6' id='input_22_29_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_22_30\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Professionnel de la sant\u00e9 qui vous a r\u00e9f\u00e9r\u00e9<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_30'>\n                            \n                            <span id='input_22_30_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_30.3' id='input_22_30_3' value='' tabindex='46'  aria-required='false'     \/>\n                                                    <label for='input_22_30_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_30_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_30.6' id='input_22_30_6' value='' tabindex='48'  aria-required='false'     \/>\n                                                    <label for='input_22_30_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_22_31\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_31'>T\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_22_31' type='tel' value='' class='medium' tabindex='50'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_22_32\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Ville<\/label>    \n                    <div class='ginput_complex ginput_container has_city ginput_container_address gform-grid-row' id='input_22_32' >\n                        <span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_22_32_3_container' >\n                                    <input type='text' name='input_32.3' id='input_22_32_3' value='' tabindex='52'   aria-required='false'    \/>\n                                    <label for='input_22_32_3' id='input_22_32_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_32.4' id='input_22_32_4' value='New Brunswick'\/><input type='hidden' class='gform_hidden' name='input_32.6' id='input_22_32_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_22_33\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Consentement pour la circoncision<\/h2><div class='gsection_description' id='gfield_description_22_33'><span style=\"color: red\">Vous devez consentir aux points suivants:<\/span><\/div><\/li><li id=\"field_22_34\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_34'><li class='gchoice gchoice_22_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Nous avons consciencieusement \u00e9valu\u00e9 les risques et b\u00e9n\u00e9fices de cette proc\u00e9dure et en avons discut\u00e9 avec notre m\u00e9decin de famille ou un autre professionnel de la sant\u00e9 avant de venir voir Dr. Christie.*'  id='choice_22_34_1' tabindex='54'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_34_1' id='label_22_34_1' class='gform-field-label gform-field-label--type-inline'>Nous avons consciencieusement \u00e9valu\u00e9 les risques et b\u00e9n\u00e9fices de cette proc\u00e9dure et en avons discut\u00e9 avec notre m\u00e9decin de famille ou un autre professionnel de la sant\u00e9 avant de venir voir Dr. Christie.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_22_38\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_38'><li class='gchoice gchoice_22_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Nous comprenons que nous consentons par proxy pour notre fils pour une proc\u00e9dure non th\u00e9rapeutique. En signant ce formulaire, nous donnons notre consentement pour cette proc\u00e9dure en tant que parents de cet enfant.*'  id='choice_22_38_1' tabindex='55'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_38_1' id='label_22_38_1' class='gform-field-label gform-field-label--type-inline'>Nous comprenons que nous consentons par proxy pour notre fils pour une proc\u00e9dure non th\u00e9rapeutique. En signant ce formulaire, nous donnons notre consentement pour cette proc\u00e9dure en tant que parents de cet enfant.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_22_37\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_37'><li class='gchoice gchoice_22_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Nous comprenons que si un parent n&#039;est pas pr\u00e9sent, nous devons fournir un consentement \u00e9crit de la part de ce parent qui confirme qu&#039;un accord fut fait de la part des deux parents pour proc\u00e9der \u00e0 la proc\u00e9dure.*'  id='choice_22_37_1' tabindex='56'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_37_1' id='label_22_37_1' class='gform-field-label gform-field-label--type-inline'>Nous comprenons que si un parent n'est pas pr\u00e9sent, nous devons fournir un consentement \u00e9crit de la part de ce parent qui confirme qu'un accord fut fait de la part des deux parents pour proc\u00e9der \u00e0 la proc\u00e9dure.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_22_36\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_36'><li class='gchoice gchoice_22_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Nous comprenons que des complications \u00e0 la suite de l&#039;op\u00e9ration puissent survenir, m\u00eame si la fr\u00e9quence varie en fonction de l&#039;exp\u00e9rience et de la comp\u00e9tence du m\u00e9decin, et quelle ne sont pas fr\u00e9quentes dans la pratique du Dr. Christie. Les complications peuvent inclure: *&lt;br&gt;&lt;br&gt;&lt;ul&gt; &lt;li&gt;Importants saignements post-op\u00e9ratoire(1\/100)&lt;\/li&gt; &lt;li&gt;Phimosis ou r\u00e9tr\u00e9cissement de l&#039;ouverture du pr\u00e9puce sur la t\u00eate du p\u00e9nis (1\/500)&lt;\/li&gt; &lt;li&gt;P\u00e9nis coinc\u00e9 dans l&#039;abdomen (1\/800)&lt;\/li&gt; &lt;li&gt;Infection n\u00e9cessitant des antibiotics (1\/1000)&lt;\/li&gt; &lt;li&gt;St\u00e9nose m\u00e9tastatique ou r\u00e9tr\u00e9cissement de l&#039;ur\u00e8tre (1\/1000)&lt;\/li&gt; &lt;li&gt;R\u00e9sultats esth\u00e9tiques sous optimaux (1\/500)&lt;\/li&gt; &lt;li&gt;Trauma \u00e0 la t\u00eate du p\u00e9nis (jamais arriv\u00e9 dans cette clinique)&lt;\/li&gt;&lt;li&gt;Blessure de l&#039;ur\u00e8tre incluant la fistule urethra-cutan\u00e9e (1\/1000)&lt;\/li&gt;&lt;li&gt;Des complications plus s\u00e9rieuses incluant la mort (jamais arriv\u00e9 dans cette clinique)&lt;\/li&gt;  &lt;\/ul&gt;'  id='choice_22_36_1' tabindex='57'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_36_1' id='label_22_36_1' class='gform-field-label gform-field-label--type-inline'>Nous comprenons que des complications \u00e0 la suite de l'op\u00e9ration puissent survenir, m\u00eame si la fr\u00e9quence varie en fonction de l'exp\u00e9rience et de la comp\u00e9tence du m\u00e9decin, et quelle ne sont pas fr\u00e9quentes dans la pratique du Dr. Christie. Les complications peuvent inclure: *<br><br><ul> <li>Importants saignements post-op\u00e9ratoire(1\/100)<\/li> <li>Phimosis ou r\u00e9tr\u00e9cissement de l'ouverture du pr\u00e9puce sur la t\u00eate du p\u00e9nis (1\/500)<\/li> <li>P\u00e9nis coinc\u00e9 dans l'abdomen (1\/800)<\/li> <li>Infection n\u00e9cessitant des antibiotics (1\/1000)<\/li> <li>St\u00e9nose m\u00e9tastatique ou r\u00e9tr\u00e9cissement de l'ur\u00e8tre (1\/1000)<\/li> <li>R\u00e9sultats esth\u00e9tiques sous optimaux (1\/500)<\/li> <li>Trauma \u00e0 la t\u00eate du p\u00e9nis (jamais arriv\u00e9 dans cette clinique)<\/li><li>Blessure de l'ur\u00e8tre incluant la fistule urethra-cutan\u00e9e (1\/1000)<\/li><li>Des complications plus s\u00e9rieuses incluant la mort (jamais arriv\u00e9 dans cette clinique)<\/li>  <\/ul><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_22_58\" class=\"gfield gfield--type-checkbox gfield--type-choice ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_58'><li class='gchoice gchoice_22_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Nous confirmons avoir compris que notre fils ne doit avoir pris aucun anti-inflammatoire dans les 7 jours pr\u00e9c\u00e9dant la proc\u00e9dure. Exemples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.*'  id='choice_22_58_1' tabindex='58'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_58_1' id='label_22_58_1' class='gform-field-label gform-field-label--type-inline'>Nous confirmons avoir compris que notre fils ne doit avoir pris aucun anti-inflammatoire dans les 7 jours pr\u00e9c\u00e9dant la proc\u00e9dure. Exemples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.*<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_22_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full ginput_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_22_66'><li class='gchoice gchoice_22_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Nous comprenons que si nous habitons \u00e0 plus de 30 minutes de la clinique, nous devons passer la nuit sur place et fournir les d\u00e9tails (adresse, num\u00e9ro de t\u00e9l\u00e9phone) de notre h\u00e9bergement d\u00e8s notre arriv\u00e9e \u00e0 la clinique. Nous comprenons que si nous ne passons pas la nuit sur place et que nous ne communiquons pas l&#039;adresse et le num\u00e9ro de t\u00e9l\u00e9phone de notre h\u00e9bergement \u00e0 Fredericton, la circoncision de notre fils sera annul\u00e9e.*'  id='choice_22_66_1' tabindex='59'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_66_1' id='label_22_66_1' class='gform-field-label gform-field-label--type-inline'>Nous comprenons que si nous habitons \u00e0 plus de 30 minutes de la clinique, nous devons passer la nuit sur place et fournir les d\u00e9tails (adresse, num\u00e9ro de t\u00e9l\u00e9phone) de notre h\u00e9bergement d\u00e8s notre arriv\u00e9e \u00e0 la clinique. 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