{"id":4180,"date":"2022-06-15T16:31:11","date_gmt":"2022-06-15T16:31:11","guid":{"rendered":"https:\/\/cllcenter.com\/reserver-une-consultation\/"},"modified":"2023-02-13T16:26:52","modified_gmt":"2023-02-13T16:26:52","slug":"reserver-une-consultation","status":"publish","type":"page","link":"https:\/\/cllcenter.com\/fr\/reserver-une-consultation\/","title":{"rendered":"Planifier une consultation"},"content":{"rendered":"<p>[vc_row css_animation=\u00a0\u00bb\u00a0\u00bb row_type=\u00a0\u00bbrow\u00a0\u00bb use_row_as_full_screen_section=\u00a0\u00bbno\u00a0\u00bb type=\u00a0\u00bbgrid\u00a0\u00bb angled_section=\u00a0\u00bbno\u00a0\u00bb text_align=\u00a0\u00bbleft\u00a0\u00bb background_image_as_pattern=\u00a0\u00bbwithout_pattern\u00a0\u00bb z_index=\u00a0\u00bb\u00a0\u00bb el_id=\u00a0\u00bbbook\u00a0\u00bb][vc_column][vc_column_text el_class=\u00a0\u00bbbookform\u00a0\u00bb]<\/p>\n<h2 style=\"text-align: center;\">PLANIFIER UNE CONSULTATION<\/h2>\n<p>[\/vc_column_text]<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f4643-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/4180#wpcf7-f4643-o1\" method=\"post\" class=\"wpcf7-form init cf7_custom_style_1\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4643\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.6.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4643-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:4643,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-quebec&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-quebec&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Oui&quot;}]},{&quot;then_field&quot;:&quot;group-noquebec&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-quebec&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Non&quot;}]},{&quot;then_field&quot;:&quot;group-canada&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-canada&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Oui&quot;}]},{&quot;then_field&quot;:&quot;group-no-canada&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-canada&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Non&quot;}]},{&quot;then_field&quot;:&quot;group-quebec-consult-yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-reason&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Probl\\u00e8me m\\u00e9dical&quot;}]},{&quot;then_field&quot;:&quot;group-quebec-stature&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-reason&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Allongement de la stature (alias allongement esth\\u00e9tique des membres)&quot;}]},{&quot;then_field&quot;:&quot;group-quebec-stature-message&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-reason&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Autre&quot;}]},{&quot;then_field&quot;:&quot;group-quebec-stature-message&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-quebec-stature&quot;,&quot;operator&quot;:&quot;not empty&quot;,&quot;if_value&quot;:&quot;&quot;}]},{&quot;then_field&quot;:&quot;group-canada-stature&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-canada-reason&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Allongement de la stature (alias allongement esth\\u00e9tique des membres)&quot;}]},{&quot;then_field&quot;:&quot;group-canada-medical&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-canada-reason&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Probl\\u00e8me m\\u00e9dical&quot;}]},{&quot;then_field&quot;:&quot;province&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;menu-province&quot;,&quot;operator&quot;:&quot;not equals&quot;,&quot;if_value&quot;:&quot;Province&quot;}]},{&quot;then_field&quot;:&quot;quebec-files&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-quebec&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Oui&quot;}]},{&quot;then_field&quot;:&quot;group-where-other&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;menu-335&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Autre&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"form-grid\">\n\t<div class=\"form-row col-2\">\n\t\t<label>Nom : <span class=\"wpcf7-form-control-wrap\" data-name=\"text-name\"><input type=\"text\" name=\"text-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/label>\n\t\t<label>Courriel : <span class=\"wpcf7-form-control-wrap\" data-name=\"email-752\"><input type=\"email\" name=\"email-752\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/label>\n\t\t<label>T\u00e9l\u00e9phone : <span class=\"wpcf7-form-control-wrap\" data-name=\"tel-418\"><input type=\"tel\" name=\"tel-418\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/label>\n\t\t<label>Date de naissance \/ \u00c2ge : <span class=\"wpcf7-form-control-wrap\" data-name=\"date-432\"><input type=\"date\" name=\"date-432\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" max=\"2026-04-18\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/label>\n\t<\/div>\n\t<div class=\"form-row\">\n\t\t<div><label>A quelle genre vous identifiez vous le plus :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"radio-gender\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-gender\" value=\"Femme\" \/><span class=\"wpcf7-list-item-label\">Femme<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-gender\" value=\"Homme\" \/><span class=\"wpcf7-list-item-label\">Homme<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-gender\" value=\"Femme transgenre\" \/><span class=\"wpcf7-list-item-label\">Femme transgenre<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-gender\" value=\"Homme transgenre\" \/><span class=\"wpcf7-list-item-label\">Homme transgenre<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-gender\" value=\"Variante ou non-conformit\u00e9 de genre\" \/><span class=\"wpcf7-list-item-label\">Variante ou non-conformit\u00e9 de genre<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-gender\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/label><\/span><\/span><\/span> <\/div>\n\t<\/div>\n\t<div class=\"form-row col-2\">\n\t\t<label>Taille : <span class=\"wpcf7-form-control-wrap\" data-name=\"text-height\"><input type=\"text\" name=\"text-height\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"En pouces \/ En centim\u00e8tres\" \/><\/span><\/label>\n\t\t<label>Poids : <span class=\"wpcf7-form-control-wrap\" data-name=\"text-height\"><input type=\"text\" name=\"text-height\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"En pouces \/ En centim\u00e8tres\" \/><\/span><\/label>\n\t<\/div>\n<div class=\"form-row\">\n<div>\n<h4>\u00cates-vous un r\u00e9sident du Canada ?<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-canada\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-canada\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-canada\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<div data-id=\"group-no-canada\" data-orig_data_id=\"group-no-canada\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<label>Dans quel pays r\u00e9sidez-vous ? <span class=\"wpcf7-form-control-wrap\" data-name=\"text-country\"><input type=\"text\" name=\"text-country\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/label>\n<div>\n<h4>Avez-vous une assurance maladie priv\u00e9e pendant votre s\u00e9jour au Canada ?<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-insurance\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-insurance\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-insurance\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"message\">\nLes frais de consultation priv\u00e9e de <strong>350 $<\/strong> sont pay\u00e9s d'avance.\nUn re\u00e7u pour l'assurance est fourni.\n<\/div>\n<\/div>\n<\/div>\n\t<div class=\"form-row\">\n<div data-id=\"group-canada\" data-orig_data_id=\"group-canada\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div>\n\t\t<h4>\u00cates-vous un r\u00e9sident du Qu\u00e9bec ?<\/h4>\n\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-quebec\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-quebec\" value=\"Oui\" \/><span class=\"wpcf7-list-item-label\">Oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-quebec\" value=\"Non\" \/><span class=\"wpcf7-list-item-label\">Non<\/span><\/label><\/span><\/span><\/span>\n\t<\/div>\n<div data-id=\"group-quebec\" data-orig_data_id=\"group-quebec\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<label>Si oui, veuillez fournir votre num\u00e9ro d'assurance-maladie\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-medicare\"><input type=\"text\" name=\"text-medicare\" value=\"\" size=\"15\" maxlength=\"15\" minlength=\"9\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n<\/label>\n<label>Date d'expiration :\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-756\"><input type=\"date\" name=\"date-756\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" min=\"2026-04-18\" aria-invalid=\"false\" \/><\/span>\n<\/label>\n<div>\n<h4>Motif de votre consultation :<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-reason\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-reason\" value=\"Probl\u00e8me m\u00e9dical\" \/><span class=\"wpcf7-list-item-label\">Probl\u00e8me m\u00e9dical<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-reason\" value=\"Allongement de la stature (alias allongement\nesth\u00e9tique des membres)\" \/><span class=\"wpcf7-list-item-label\">Allongement de la stature (alias allongement\nesth\u00e9tique des membres)<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<div data-id=\"group-quebec-stature\" data-orig_data_id=\"group-quebec-stature\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<h4 style=\"margin-top:20px;\">Veuillez choisir le type de consultation :<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-quebec-stature\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-quebec-stature\" value=\"Consultation virtuelle\" \/><span class=\"wpcf7-list-item-label\">Consultation virtuelle<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-quebec-stature\" value=\"Consultation en personne\" \/><span class=\"wpcf7-list-item-label\">Consultation en personne<\/span><\/label><\/span><\/span><\/span>\n<div data-id=\"group-quebec-stature-message\" data-orig_data_id=\"group-quebec-stature-message\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class=\"message\">\nLes frais de consultation sont de <strong>350 $<\/strong> pour une premi\u00e8re visite et de <strong>150 $<\/strong> pour un suivi.\n<\/div>\n<\/div>\n<\/div>\n<div data-id=\"group-quebec-consult-yes\" data-orig_data_id=\"group-quebec-consult-yes\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class=\"message\">\nVotre consultation doit se faire uniquement en personne.\n<\/div>\n<\/div>\n<\/div>\n\n<\/div>\n<div data-id=\"group-noquebec\" data-orig_data_id=\"group-noquebec\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div><h4>De quelle province venez-vous ?<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-province\"><select name=\"menu-province\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"Province\">Province<\/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=\"Nouvelle-\u00c9cosse\">Nouvelle-\u00c9cosse<\/option><option value=\"Ontario\">Ontario<\/option><option value=\"\u00cele-du-Prince-\u00c9douard\">\u00cele-du-Prince-\u00c9douard<\/option><option value=\"Saskatchewan\">Saskatchewan<\/option><\/select><\/span><\/div>\n<div data-id=\"province\" data-orig_data_id=\"province\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div><h4 style=\"margin-top:20px;\">Veuillez choisir le type de consultation :<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-canada-constype\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-canada-constype\" value=\"Consultation virtuelle\" \/><span class=\"wpcf7-list-item-label\">Consultation virtuelle<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-canada-constype\" value=\"Consultation en personne\" \/><span class=\"wpcf7-list-item-label\">Consultation en personne<\/span><\/label><\/span><\/span><\/span><\/div>\n<div><h4 style=\"margin-top:20px;\">Motif de votre consultation :<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-canada-reason\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-canada-reason\" value=\"Probl\u00e8me m\u00e9dical\" \/><span class=\"wpcf7-list-item-label\">Probl\u00e8me m\u00e9dical<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-canada-reason\" value=\"Allongement de la stature (alias allongement\nesth\u00e9tique des membres)\" \/><span class=\"wpcf7-list-item-label\">Allongement de la stature (alias allongement\nesth\u00e9tique des membres)<\/span><\/label><\/span><\/span><\/span><\/div>\n<div data-id=\"group-canada-stature\" data-orig_data_id=\"group-canada-stature\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class=\"message\">\nLes frais de consultation sont de <strong>350 $<\/strong> pour une premi\u00e8re visite.<\/div>\n<\/div>\n<div data-id=\"group-canada-medical\" data-orig_data_id=\"group-canada-medical\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class=\"message\">\nLes frais de consultation sont de <strong>150 $<\/strong> pour une premi\u00e8re visite.<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\t<div class=\"form-row\">\n\t\t<div>\n\t\t\t<h4>Partie du corps affect\u00e9e :<\/h4>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-zones\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Cheville\" \/><span class=\"wpcf7-list-item-label\">Cheville<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Coude\" \/><span class=\"wpcf7-list-item-label\">Coude<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"F\u00e9mur\" \/><span class=\"wpcf7-list-item-label\">F\u00e9mur<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Pied\" \/><span class=\"wpcf7-list-item-label\">Pied<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Avant-bras\" \/><span class=\"wpcf7-list-item-label\">Avant-bras<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Hanche\" \/><span class=\"wpcf7-list-item-label\">Hanche<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Hum\u00e9rus\" \/><span class=\"wpcf7-list-item-label\">Hum\u00e9rus<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Genou\" \/><span class=\"wpcf7-list-item-label\">Genou<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"\u00c9paule\" \/><span class=\"wpcf7-list-item-label\">\u00c9paule<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Tibia\" \/><span class=\"wpcf7-list-item-label\">Tibia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Poignet\" \/><span class=\"wpcf7-list-item-label\">Poignet<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-zones[]\" value=\"Autre\" \/><span class=\"wpcf7-list-item-label\">Autre<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/div>\n<div>\n\t\t<h4>Nom de votre maladie ou probl\u00e8me de sant\u00e9 :<\/h4>\n <span class=\"wpcf7-form-control-wrap\" data-name=\"text-other-cond\"><input type=\"text\" name=\"text-other-cond\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Veuillez pr\u00e9ciser\" \/><\/span>\n<\/div>\n\t<\/div>\n<div>\n<h4>Comment avez-vous entendu parler de nous ?<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"menu-335\"><select name=\"menu-335\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Instagram \/ Facebook\">Instagram \/ Facebook<\/option><option value=\"Recherche sur Google\">Recherche sur Google<\/option><option value=\"Bouche \u00e0 oreille\">Bouche \u00e0 oreille<\/option><option value=\"Radio \/ TV\">Radio \/ TV<\/option><option value=\"Article de presse \/ Publicit\u00e9 YouTube\">Article de presse \/ Publicit\u00e9 YouTube<\/option><option value=\"Forum \/ Blog\">Forum \/ Blog<\/option><\/select><\/span>\n<div data-id=\"group-where-other\" data-orig_data_id=\"group-where-other\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-other\"><input type=\"text\" name=\"text-other\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Veuillez pr\u00e9ciser\" \/><\/span>\n<\/div>\n<\/div>\n\t<div class=\"form-row\">\n\t\t<div>\n\t\t\t<h4>T\u00e9l\u00e9chargez vos photos cliniques ou vos radiographies\/imageries :<\/h4>\n\t\t\t<span class=\"wpcf7-form-control-wrap\" data-name=\"file-475\"><input type=\"file\" name=\"file-475\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.heic,.pdf\" aria-invalid=\"false\" 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