{"id":76,"date":"2014-09-02T20:29:19","date_gmt":"2014-09-02T20:29:19","guid":{"rendered":"https:\/\/www.embrunortho.com\/?page_id=76"},"modified":"2025-01-16T14:45:35","modified_gmt":"2025-01-16T14:45:35","slug":"referer-un-patient","status":"publish","type":"page","link":"https:\/\/www.embrunortho.com\/fr\/referer-un-patient\/","title":{"rendered":"R\u00e9f\u00e9rer un patient"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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 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var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Formulaire pour r\u00e9f\u00e9rer votre patient<\/h2>\n                            <p class='gform_description'>S\u2019il-vous-pla\u00eet remplir le formulaire et le soumettre.  Merci de votre r\u00e9f\u00e9rence.<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/fr\/wp-json\/wp\/v2\/pages\/76' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_12\" class=\"gfield gfield--type-select 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_2_12'>R\u00e9f\u00e9rer le patient \u00e0<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_2_12' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\"><option value='Dr. Carolyne Thain'>Dr. Carolyne Thain<\/option><option value='Dr. Noh\u00e9 Sassi'>Dr. Noh\u00e9 Sassi<\/option><\/select><\/div><\/div><fieldset id=\"field_2_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Nom du patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_2_1'>\n                            <span id='input_2_1_3_container' class='name_first gform-grid-col'>\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value=''   aria-required='true'    \/>\n                                                    <label for='input_2_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                               <\/span>\n                            <span id='input_2_1_6_container' class='name_last gform-grid-col'>\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value=''   aria-required='true'    \/>\n                                                    <label for='input_2_1_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/fieldset><div id=\"field_2_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_2_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_2_2' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_2_2_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_2_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_2' class='gform_hidden' value='https:\/\/www.embrunortho.com\/extras\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class='gfield_label gform-field-label' for='input_2_14'>Courriel du patient<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_2_14' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_11\" 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_2_11'>Num\u00e9ro de t\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_2_11' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><label class='gfield_label gform-field-label' for='input_2_13'>Num\u00e9ro de t\u00e9l\u00e9phone (alternatif)<\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_2_13' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_15\" class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Adresse du patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_2_15'>\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_15_1_container'>\n                                        <input type='text' name='input_15.1' id='input_2_15_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_15_1' id='input_2_15_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_15_3_container'>\n                                    <input type='text' name='input_15.3' id='input_2_15_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_15_3' id='input_2_15_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_2_15_4_container'>\n                                        <select name='input_15.4' id='input_2_15_4'     aria-required='true'><option value='' selected='selected'><\/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_2_15_4' id='input_2_15_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_2_15_5_container'>\n                                    <input type='text' name='input_15.5' id='input_2_15_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_15_5' id='input_2_15_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_2_15_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_2_3\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Nom du parent (si applicable)<\/legend><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_2_3'>\n                            <span id='input_2_3_3_container' class='name_first gform-grid-col'>\n                                                    <input type='text' name='input_3.3' id='input_2_3_3' value=''   aria-required='false'    \/>\n                                                    <label for='input_2_3_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                               <\/span>\n                            <span id='input_2_3_6_container' class='name_last gform-grid-col'>\n                                                    <input type='text' name='input_3.6' id='input_2_3_6' value=''   aria-required='false'    \/>\n                                                    <label for='input_2_3_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/fieldset><fieldset id=\"field_2_10\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Nom du parent additionnel (si applicable)<\/legend><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_2_10'>\n                            <span id='input_2_10_3_container' class='name_first gform-grid-col'>\n                                                    <input type='text' name='input_10.3' id='input_2_10_3' value=''   aria-required='false'    \/>\n                                                    <label for='input_2_10_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                               <\/span>\n                            <span id='input_2_10_6_container' class='name_last gform-grid-col'>\n                                                    <input type='text' name='input_10.6' id='input_2_10_6' value=''   aria-required='false'    \/>\n                                                    <label for='input_2_10_6' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/fieldset><fieldset id=\"field_2_4\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"><legend class='gfield_label gform-field-label gfield_label_before_complex'>Inqui\u00e9tudes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_4'><div class='gchoice gchoice_2_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Chevauchement dentaire'  id='choice_2_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_1' id='label_2_4_1' class='gform-field-label gform-field-label--type-inline'>Chevauchement dentaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='Espacement dentaire'  id='choice_2_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_2' id='label_2_4_2' class='gform-field-label gform-field-label--type-inline'>Espacement dentaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='Dents manquantes'  id='choice_2_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_3' id='label_2_4_3' class='gform-field-label gform-field-label--type-inline'>Dents manquantes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.4' type='checkbox'  value='Occlusion crois\u00e9e (Ant\u00e9rieure \/ Post\u00e9rieure)'  id='choice_2_4_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_4' id='label_2_4_4' class='gform-field-label gform-field-label--type-inline'>Occlusion crois\u00e9e (Ant\u00e9rieure \/ Post\u00e9rieure)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.5' type='checkbox'  value='Troubles de croissance (Classe II \/ Classe III \/ Asym\u00e9trie)'  id='choice_2_4_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_5' id='label_2_4_5' class='gform-field-label gform-field-label--type-inline'>Troubles de croissance (Classe II \/ Classe III \/ Asym\u00e9trie)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.6' type='checkbox'  value='Probl\u00e8mes en dentition mixte \/ Traitement interceptif'  id='choice_2_4_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_6' id='label_2_4_6' class='gform-field-label gform-field-label--type-inline'>Probl\u00e8mes en dentition mixte \/ Traitement interceptif<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.7' type='checkbox'  value='Traitement pr\u00e9-proth\u00e9tique '  id='choice_2_4_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_7' id='label_2_4_7' class='gform-field-label gform-field-label--type-inline'>Traitement pr\u00e9-proth\u00e9tique <\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.8' type='checkbox'  value='Chirurgie orthognathique'  id='choice_2_4_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_4_8' id='label_2_4_8' class='gform-field-label gform-field-label--type-inline'>Chirurgie orthognathique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_4_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.9' type='checkbox'  value='Invisalign'  id='choice_2_4_9'   \/>\n\t\t\t\t\t\t\t\t<label 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