{"id":6703,"date":"2021-12-17T00:54:12","date_gmt":"2021-12-17T00:54:12","guid":{"rendered":"https:\/\/gentleproceduresnb.ca\/?page_id=6703"},"modified":"2021-12-17T14:04:16","modified_gmt":"2021-12-17T14:04:16","slug":"inscription","status":"publish","type":"page","link":"https:\/\/gentleproceduresnb.ca\/fr\/penis-frenulectomie-frenuloplastie\/inscription\/","title":{"rendered":"Frenulectomie inscription"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6703\" class=\"elementor elementor-6703 elementor-5085\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-60ad2b9f elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"60ad2b9f\" data-element_type=\"section\" data-e-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-1a319f19\" data-id=\"1a319f19\" data-element_type=\"column\" data-e-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-5402d5ef elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"5402d5ef\" data-element_type=\"section\" data-e-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-5b84ae73\" data-id=\"5b84ae73\" data-element_type=\"column\" data-e-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-2e5e5b60 elementor-widget elementor-widget-heading\" data-id=\"2e5e5b60\" data-element_type=\"widget\" data-e-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\">Inscription pour une fr\u00e9nulectomie<\/h1>\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-6427feaa\" data-id=\"6427feaa\" data-element_type=\"column\" data-e-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-ebae0e5 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ebae0e5\" data-element_type=\"section\" data-e-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-2b21d6fd\" data-id=\"2b21d6fd\" data-element_type=\"column\" data-e-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-48b34708 elementor-widget elementor-widget-text-editor\" data-id=\"48b34708\" data-element_type=\"widget\" data-e-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>Compl\u00e9tez le formulaire d\u2019inscription ci-dessous pour une proc\u00e9dure de fr\u00e9nulectomie<\/p><p>Nous vous rappellerons pour confirmer votre rendez-vous et r\u00e9pondre \u00e0 vos questions.<\/p><p>Merci d\u2019avoir r\u00e9serv\u00e9 avec nous.<\/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-400fecdd 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=\"400fecdd\" data-element_type=\"widget\" data-e-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_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_33' ><form method='post' enctype='multipart\/form-data'  id='gform_33'  action='\/fr\/wp-json\/wp\/v2\/pages\/6703' data-formid='33' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_33' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_33_42\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_42'>Email<\/label><div class='ginput_container'><input name='input_42' id='input_33_42' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_33_42'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/li><li id=\"field_33_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 du patient<\/h2><\/li><li id=\"field_33_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*<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_33_1'>\n                            \n                            <span id='input_33_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_33_1_3' value='' tabindex='2'  aria-required='true'     \/>\n                                                    <label for='input_33_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_33_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_33_1_6' value='' tabindex='4'  aria-required='true'     \/>\n                                                    <label for='input_33_1_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_33_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_33_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_33_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='6'  placeholder='mm\/jj\/aaaa' aria-describedby=\"input_33_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_33_2_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_33_2' class='gform_hidden' value='https:\/\/gentleproceduresnb.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_33_3\" 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_33_3'>Num\u00e9ro de carte d&#039;assurance maladie<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_33_3' type='text' value='' class='medium'   tabindex='7'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_33_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_33_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_33_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_33_4_1' value='' tabindex='8'   aria-required='true'    \/>\n                                        <label for='input_33_4_1' id='input_33_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_33_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_33_4_2' value='' tabindex='9'    aria-required='false'   \/>\n                                        <label for='input_33_4_2' id='input_33_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_33_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_33_4_3' value='' tabindex='10'   aria-required='true'    \/>\n                                    <label for='input_33_4_3' id='input_33_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_33_4_4_container' >\n                                        <select name='input_4.4' id='input_33_4_4' tabindex='11'    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_33_4_4' id='input_33_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_33_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_33_4_5' value='' tabindex='13'   aria-required='true'    \/>\n                                    <label for='input_33_4_5' id='input_33_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_33_4_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_33_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_33_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_33_5' type='tel' value='' class='medium' tabindex='14'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_33_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_33_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_33_6' type='email' value='' class='medium' tabindex='15'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_33_7\" 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' >Personne \u00e0 contacter en cas d&#039;urgence*<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_33_7'>\n                            \n                            <span id='input_33_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_33_7_3' value='' tabindex='17'  aria-required='true'     \/>\n                                                    <label for='input_33_7_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_33_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_33_7_6' value='' tabindex='19'  aria-required='true'     \/>\n                                                    <label for='input_33_7_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_33_8\" 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_33_8'>Num\u00e9ro de contact en cas d&#039;urgence*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_33_8' type='tel' value='' class='medium' tabindex='21'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_33_40\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_40'>O\u00f9 avez vous entendu parler de nous?<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_33_40' type='text' value='' class='medium'   tabindex='22'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_33_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full 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' >Raisons pous lesquelles vous cherchez \u00e0 vous faire op\u00e9rer?<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_33_41'><li class='gchoice gchoice_33_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Inconfort et saignement'  id='choice_33_41_1' tabindex='23'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_41_1' id='label_33_41_1' class='gform-field-label gform-field-label--type-inline'>Inconfort et saignement<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_33_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='\u00c9jaculation pr\u00e9coce'  id='choice_33_41_2' tabindex='24'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_41_2' id='label_33_41_2' class='gform-field-label gform-field-label--type-inline'>\u00c9jaculation pr\u00e9coce<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_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_33_12\" 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' >Vous connaissez-vous pour faire des ecchymoses facilement?*<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_33_12'>\n\t\t\t<li class='gchoice gchoice_33_12_0'>\n\t\t\t\t<input name='input_12' type='radio' value='Oui'  id='choice_33_12_0' tabindex='25'   \/>\n\t\t\t\t<label for='choice_33_12_0' id='label_33_12_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_33_12_1'>\n\t\t\t\t<input name='input_12' type='radio' value='Non'  id='choice_33_12_1' tabindex='26'   \/>\n\t\t\t\t<label for='choice_33_12_1' id='label_33_12_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_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' >Avez-vous des saignements de nez souvent?*<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_33_13'>\n\t\t\t<li class='gchoice gchoice_33_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Oui'  id='choice_33_13_0' tabindex='27'   \/>\n\t\t\t\t<label for='choice_33_13_0' id='label_33_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_33_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='Non'  id='choice_33_13_1' tabindex='28'   \/>\n\t\t\t\t<label for='choice_33_13_1' id='label_33_13_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_22\" 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' >Avez-vous d\u00e9ja eu des saignements prolong\u00e9s apr\u00e8s une proc\u00e8dure chez le dentiste?*<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_33_22'>\n\t\t\t<li class='gchoice gchoice_33_22_0'>\n\t\t\t\t<input name='input_22' type='radio' value='Oui'  id='choice_33_22_0' tabindex='29'   \/>\n\t\t\t\t<label for='choice_33_22_0' id='label_33_22_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_33_22_1'>\n\t\t\t\t<input name='input_22' type='radio' value='Non'  id='choice_33_22_1' tabindex='30'   \/>\n\t\t\t\t<label for='choice_33_22_1' id='label_33_22_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_21\" 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' >Avez-vous eu des probl\u00e8mes m\u00e9dicaux ou des pertes de sang depuis votre naissance?*<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_33_21'>\n\t\t\t<li class='gchoice gchoice_33_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='Oui'  id='choice_33_21_0' tabindex='31'   \/>\n\t\t\t\t<label for='choice_33_21_0' id='label_33_21_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_33_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='Non'  id='choice_33_21_1' tabindex='32'   \/>\n\t\t\t\t<label for='choice_33_21_1' id='label_33_21_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_20\" 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 famille a-t-elle un historique de probl\u00e8mes de saignement?*<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_33_20'>\n\t\t\t<li class='gchoice gchoice_33_20_0'>\n\t\t\t\t<input name='input_20' type='radio' value='Oui'  id='choice_33_20_0' tabindex='33'   \/>\n\t\t\t\t<label for='choice_33_20_0' id='label_33_20_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_33_20_1'>\n\t\t\t\t<input name='input_20' type='radio' value='Non'  id='choice_33_20_1' tabindex='34'   \/>\n\t\t\t\t<label for='choice_33_20_1' id='label_33_20_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_19\" 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' >Avez-vous des raisons de croire que vous avez une faible pression art\u00e9rielle 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_33_19'>\n\t\t\t<li class='gchoice gchoice_33_19_0'>\n\t\t\t\t<input name='input_19' type='radio' value='Oui'  id='choice_33_19_0' tabindex='35'   \/>\n\t\t\t\t<label for='choice_33_19_0' id='label_33_19_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_33_19_1'>\n\t\t\t\t<input name='input_19' type='radio' value='Non'  id='choice_33_19_1' tabindex='36'   \/>\n\t\t\t\t<label for='choice_33_19_1' id='label_33_19_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_18\" 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' >Avez-vous d\u00e9ja perdu connaissance apr\u00e8s une injection ou une proc\u00e9dure m\u00e9dicale?*<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_33_18'>\n\t\t\t<li class='gchoice gchoice_33_18_0'>\n\t\t\t\t<input name='input_18' type='radio' value='Oui'  id='choice_33_18_0' tabindex='37'   \/>\n\t\t\t\t<label for='choice_33_18_0' id='label_33_18_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_33_18_1'>\n\t\t\t\t<input name='input_18' type='radio' value='Non'  id='choice_33_18_1' tabindex='38'   \/>\n\t\t\t\t<label for='choice_33_18_1' id='label_33_18_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_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' >Avez-vous d\u00e9ja \u00e9t\u00e9 irrit\u00e9 par une bande serr\u00e9e sur le dessous de votre p\u00e9nis qui causait des douleurs ou des saignements durant l&#039;acte sexuel?*<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_33_17'>\n\t\t\t<li class='gchoice gchoice_33_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Oui'  id='choice_33_17_0' tabindex='39'   \/>\n\t\t\t\t<label for='choice_33_17_0' id='label_33_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_33_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='Non'  id='choice_33_17_1' tabindex='40'   \/>\n\t\t\t\t<label for='choice_33_17_1' id='label_33_17_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_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_33_23'>Si oui, d\u00e9taillez:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_23' id='input_33_23' class='textarea medium' tabindex='41'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_33_24\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_33_24'>Inscrivez toutes les m\u00e9dications que vous prenez pr\u00e9sentement:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_33_24' class='textarea medium' tabindex='42' aria-describedby=\"gfield_description_33_24\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_33_24'>(nom\/dosage)<\/div><\/li><li id=\"field_33_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<\/h2><div class='gsection_description' id='gfield_description_33_33'><span style=\"color: red\">Vous devez consentir aux points suivants:<\/span><\/div><\/li><li id=\"field_33_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_33_34'><li class='gchoice gchoice_33_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='J&#039;ai consciencieusement \u00e9valu\u00e9 les risques et b\u00e9n\u00e9fices de cette proc\u00e9dure et j&#039;en ai discut\u00e9 avec mon m\u00e9decin de famille ou un autre professionnel de la sant\u00e9 avant de venir voir Dr. Christie.*'  id='choice_33_34_1' tabindex='43'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_34_1' id='label_33_34_1' class='gform-field-label gform-field-label--type-inline'>J'ai consciencieusement \u00e9valu\u00e9 les risques et b\u00e9n\u00e9fices de cette proc\u00e9dure et j'en ai discut\u00e9 avec mon 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_33_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_33_38'><li class='gchoice gchoice_33_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Je comprends 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;Infection n\u00e9cessitant des antibiotics(1\/1000)&lt;\/li&gt;&lt;li&gt;R\u00e9sultats esth\u00e9tiques sous optimaux (1\/500)&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;Trauma \u00e0 la t\u00eate du p\u00e9nis (jamais arriv\u00e9 dans cette clinique)&lt;\/li&gt;&lt;li&gt;Aucun changement dans mes sympt\u00f4mes d&#039;\u00e9jaculation pr\u00e9coce&lt;\/li&gt;&lt;li&gt; Aggravation de mon \u00e9jaculation pr\u00e9coce&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;Complications plus s\u00e9rieuses incluant la mort (jamais arriv\u00e9 dans cette clinique)&lt;\/li&gt;&lt;\/ul&gt;'  id='choice_33_38_1' tabindex='44'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_38_1' id='label_33_38_1' class='gform-field-label gform-field-label--type-inline'>Je comprends 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>Infection n\u00e9cessitant des antibiotics(1\/1000)<\/li><li>R\u00e9sultats esth\u00e9tiques sous optimaux (1\/500)<\/li><li>St\u00e9nose m\u00e9tastatique ou r\u00e9tr\u00e9cissement de l'ur\u00e8tre (1\/1000)<\/li><li>Trauma \u00e0 la t\u00eate du p\u00e9nis (jamais arriv\u00e9 dans cette clinique)<\/li><li>Aucun changement dans mes sympt\u00f4mes d'\u00e9jaculation pr\u00e9coce<\/li><li> Aggravation de mon \u00e9jaculation pr\u00e9coce<\/li><li>Blessure de l'ur\u00e8tre incluant la fistule urethra-cutan\u00e9e (1\/1000)<\/li><li>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_33_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_33_37'><li class='gchoice gchoice_33_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Je comprend qu&#039;il puisse \u00eatre n\u00e9cessaire pour le docteur d&#039;utiliser certaines de ces techniques pour arr\u00eater des saignements le cas \u00e9ch\u00e9ant.*&lt;br \/&gt;&lt;br \/&gt;&lt;ul&gt; &lt;li&gt;Compresses&lt;\/li&gt; &lt;li&gt;Colle pour la peau&lt;\/li&gt; &lt;li&gt;Caut\u00e9risation bipolaire&lt;\/li&gt; &lt;li&gt;Points de suture&lt;\/li&gt; &lt;\/ul&gt;'  id='choice_33_37_1' tabindex='45'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_37_1' id='label_33_37_1' class='gform-field-label gform-field-label--type-inline'>Je comprend qu'il puisse \u00eatre n\u00e9cessaire pour le docteur d'utiliser certaines de ces techniques pour arr\u00eater des saignements le cas \u00e9ch\u00e9ant.*<br \/><br \/><ul> <li>Compresses<\/li> <li>Colle pour la peau<\/li> <li>Caut\u00e9risation bipolaire<\/li> <li>Points de suture<\/li> <\/ul><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_33_35\" 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_33_35'><li class='gchoice gchoice_33_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Je confirme avoir compris ne devoir prendre aucun anti-inflammatoire dans les 7 jours avant l&#039;intervention et 2 jours apr\u00e8s. Exemples: ADVIL, IBUPROFEN, ASPIRIN, MOTRIN, etc.'  id='choice_33_35_1' tabindex='46'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_33_35_1' id='label_33_35_1' class='gform-field-label gform-field-label--type-inline'>Je confirme avoir compris ne devoir prendre aucun anti-inflammatoire dans les 7 jours avant l'intervention et 2 jours apr\u00e8s. 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