{"id":1111,"date":"2023-08-08T17:30:57","date_gmt":"2023-08-08T15:30:57","guid":{"rendered":"https:\/\/maxilloriviera.ch\/informations-patients\/questionnaire-medical-en-ligne\/"},"modified":"2024-04-10T13:01:59","modified_gmt":"2024-04-10T11:01:59","slug":"questionnaire-medical-en-ligne","status":"publish","type":"page","link":"https:\/\/maxilloriviera.ch\/en\/informations-patients\/questionnaire-medical-en-ligne\/","title":{"rendered":"Online medical questionnaire"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Before your first medical consultation, you can pre-register online using our secure form for confidential patient data.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">After completing our electronic form of personal data and medical information (see online registration form below), make sure to click on the \u201csave\u201d button at the bottom of the page to automatically send us your completed secure form.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">During your first appointment, we will already have your personal data available to be reviewed and signed in the presence of your surgeon.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The confidentiality and security of your personal information is subject to medical confidentiality and we guarantee you an electronic transmission of these forms by a totally secure server.<\/p>\n\n\n\n<div style=\"height:31px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h3 class=\"wp-block-heading\">ONLINE MEDICAL REGISTRATION FORM<\/h3>\n\n\n<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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_5' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Online medical questionnaire<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/en\/wp-json\/wp\/v2\/pages\/1111' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_4'><span class='gform-field-label__text'>name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_5'><span class='gform-field-label__text'>First name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_5_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half 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_5_3'><span class='gform-field-label__text'>Date of birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_5_3'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_3'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_5_3' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_5_3' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_5_3' aria-label='Date of birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_5_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_6'><span class='gform-field-label__text'>Nationality<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_5_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full 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' ><span class='gform-field-label__text'>Address<\/span><\/legend>    \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_5_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_5_7_1' value=''    aria-required='false'    \/>\n                                        <label for='input_5_7_1' id='input_5_7_1_label' class='gform-field-label gform-field-label--type-sub '>Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_5_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_7_2' id='input_5_7_2_label' class='gform-field-label gform-field-label--type-sub '>2nd line address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_5_7_3' value=''    aria-required='false'    \/>\n                                    <label for='input_5_7_3' id='input_5_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_7_4_container' >\n                                        <input type='text' name='input_7.4' id='input_5_7_4' value=''      aria-required='false'    \/>\n                                        <label for='input_5_7_4' id='input_5_7_4_label' class='gform-field-label gform-field-label--type-sub '>Canton<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_5_7_5' value=''    aria-required='false'    \/>\n                                    <label for='input_5_7_5' id='input_5_7_5_label' class='gform-field-label gform-field-label--type-sub '>Postal code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_5_7_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_5_8\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half 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_5_8'><span class='gform-field-label__text'>E-mail<\/span><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_8' id='input_5_8' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half 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_5_9'><span class='gform-field-label__text'>Business phone number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_5_9' type='tel' value='' class='large'  placeholder='Residence' aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_5_10\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_10'><span class='gform-field-label__text'>Private phone number<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_5_10' type='tel' value='' class='large'  placeholder='Residence'  aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_5_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'><span class='gform-field-label__text'>Phone number<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_5_11' type='tel' value='' class='large'  placeholder='Residence'  aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_5_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'><span class='gform-field-label__text'>Marital status<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_13'><span class='gform-field-label__text'>Occupation<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_5_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_14\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_14'><span class='gform-field-label__text'>Parents\/guardian<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_5_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_15'><span class='gform-field-label__text'>Health Insurance<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_5_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_17'><span class='gform-field-label__text'>AVS number<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_17' id='input_5_17' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_18\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_18'><span class='gform-field-label__text'>Employer<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_5_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_19'><span class='gform-field-label__text'>Are you receiving social benefits (Social, PC, AI)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_5_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_20'><span class='gform-field-label__text'>You are referred by Doctor (name\/city)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_5_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_21\" class=\"gfield gfield--type-text gfield--input-type-text 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_5_21'><span class='gform-field-label__text'>Your family doctor (name\/city)<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_5_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Anamn\u00e8se \u2013 \u00e0 remplir de mani\u00e8re exacte, ces renseignements \u00e9tant importants pour vous-m\u00eame et le m\u00e9decin<\/h3><\/div><fieldset id=\"field_5_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>1 Avez-vous \u00e9t\u00e9 hospitalis\u00e9 il y a moins de 5 ans ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_30'>\n\t\t\t<div class='gchoice gchoice_5_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Oui'  id='choice_5_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_0' id='label_5_30_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Non'  id='choice_5_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_30_1' id='label_5_30_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_31\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_31'><span class='gform-field-label__text'>Si Oui, pourquoi :<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_31' id='input_5_31' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>2 Prenez-vous r\u00e9guli\u00e8rement des m\u00e9dicaments (Sintrom, Bisphosphonates, etc\u2026) ou \u00eates-vous suivi pour une maladie ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_32'>\n\t\t\t<div class='gchoice gchoice_5_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Oui'  id='choice_5_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_32_0' id='label_5_32_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Non'  id='choice_5_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_32_1' id='label_5_32_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_33\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_33'><span class='gform-field-label__text'>Si oui, le(s) quel(s)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_33' id='input_5_33' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>3 Etes-vous sous-anticoagulants ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_34'>\n\t\t\t<div class='gchoice gchoice_5_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Oui'  id='choice_5_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_0' id='label_5_34_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Non'  id='choice_5_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_34_1' id='label_5_34_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_35'><span class='gform-field-label__text'>Si oui, le(s) quel(s)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_5_35' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>4 Etes-vous allergique (injections, m\u00e9dicaments, autres allergies : asthme, rhume des foins) ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_36'>\n\t\t\t<div class='gchoice gchoice_5_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Oui'  id='choice_5_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_0' id='label_5_36_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='Non'  id='choice_5_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_36_1' id='label_5_36_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_37\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_37'><span class='gform-field-label__text'>Si oui, le(s) quel(s)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_5_37' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>5 Etes-vous enceinte ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_38'>\n\t\t\t<div class='gchoice gchoice_5_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Oui'  id='choice_5_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_0' id='label_5_38_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Non'  id='choice_5_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_59\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Probl\u00e8mes particuliers<\/h3><\/div><div id=\"field_5_39\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_39'><span class='gform-field-label__text'>Si oui, de combien de mois :<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_39' id='input_5_39' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>6 Cardio-vasculaires (Troubles du rythme, hyper ou hypotension, autre) ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_41'>\n\t\t\t<div class='gchoice gchoice_5_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Oui'  id='choice_5_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_0' id='label_5_41_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Non'  id='choice_5_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_1' id='label_5_41_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_42\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_42'><span class='gform-field-label__text'>Si oui, le(s) quel(s)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_5_42' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>7 Diab\u00e8te ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_43'>\n\t\t\t<div class='gchoice gchoice_5_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Oui'  id='choice_5_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_0' id='label_5_43_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Non'  id='choice_5_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_43_1' id='label_5_43_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_44\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_44'><span class='gform-field-label__text'>Si oui, le(s) quel(s)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_5_44' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>8 Ulc\u00e8re d&#039;estomac ou du duod\u00e9num ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_45'>\n\t\t\t<div class='gchoice gchoice_5_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Oui'  id='choice_5_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_45_0' id='label_5_45_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Non'  id='choice_5_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_45_1' id='label_5_45_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_46\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_46'><span class='gform-field-label__text'>Si oui, le(s) quel(s)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_5_46' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>9 H\u00e9patite virale\/ HIV\/ autre maladie \u00e0 virus ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_47'>\n\t\t\t<div class='gchoice gchoice_5_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Oui'  id='choice_5_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_47_0' id='label_5_47_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Non'  id='choice_5_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_47_1' id='label_5_47_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_48'><span class='gform-field-label__text'>Si oui, le(s) quel(s)<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_5_48' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>10 Proth\u00e8se de genou\/hanche\/ autre mat\u00e9riel \u00e9tranger ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_49'>\n\t\t\t<div class='gchoice gchoice_5_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Oui'  id='choice_5_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_49_0' id='label_5_49_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='Non'  id='choice_5_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_49_1' id='label_5_49_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_60\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Habitudes<\/h3><\/div><div id=\"field_5_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_50'><span class='gform-field-label__text'>Si oui, la(les) quelle(s) :<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_5_50' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>12 Tabac ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_52'>\n\t\t\t<div class='gchoice gchoice_5_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Oui'  id='choice_5_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_52_0' id='label_5_52_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Non'  id='choice_5_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_52_1' id='label_5_52_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_53\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_53'><span class='gform-field-label__text'>si oui, \u00e0 quelle fr\u00e9quence :<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_5_53' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>13 Alcool ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_54'>\n\t\t\t<div class='gchoice gchoice_5_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Oui'  id='choice_5_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_0' id='label_5_54_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Non'  id='choice_5_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_54_1' id='label_5_54_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_56\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_56'><span class='gform-field-label__text'>si oui, \u00e0 quelle fr\u00e9quence :<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_56' id='input_5_56' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>14 Autres substances\/drogues ?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_57'>\n\t\t\t<div class='gchoice gchoice_5_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Oui'  id='choice_5_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_57_0' id='label_5_57_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Non'  id='choice_5_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_57_1' id='label_5_57_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_55\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_5_55'><span class='gform-field-label__text'>si oui, \u00e0 quelle fr\u00e9quence et la(les)quelle (s) :<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_5_55' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_5_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>I would like to opt for the counting system<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_22'>\n\t\t\t<div class='gchoice gchoice_5_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Sending the invoice directly from the doctor to my health insurance (Third Party Paying)'  id='choice_5_22_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_0' id='label_5_22_0' class='gform-field-label gform-field-label--type-inline'>Sending the invoice directly from the doctor to my health insurance (Third Party Paying)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Sending the invoice directly from the doctor to my health insurance (Third Party Paying)'  id='choice_5_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_22_1' id='label_5_22_1' class='gform-field-label gform-field-label--type-inline'>Sending the invoice directly from the doctor to my health insurance (Third Party Paying)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_24\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Read<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_5_24'><div class='gfield_consent_description_text' tabindex='0'>By this document, I authorize the online consultation, based on the insurance card, of the data necessary for billing and its recovery and to transmit them both to the institution issuing the invoice, e.g., in electronic form via the MEDIPORT network, and to the entity responsible for any collection (e.g., collection agency) or to the lawyer (or other third party) handling this matter, as well as to the relevant authorities of the State (e.g., debt enforcement office, court). I irrevocably release Dr. Portier-Marret from medical confidentiality vis-\u00e0-vis the aforementioned individuals, authorities, and courts. I also authorize him to recover his invoices by any legal means. Furthermore, I expressly consent herewith to the physician or a person authorized by him making inquiries about my solvency with the necessary data. My physician is entitled to request medical records concerning me for consultation and to communicate medical results to the subsequent treating physician. By my signature, I declare that the above-mentioned information is true and that I am aware that the physician sends his invoices in electronic form via the MediPort network.<br \/>\r\n<br \/>\r\nI acknowledge and accept that in case of late payment, the following fees will be applied: Processing fees (at the earliest 80 days from the date of invoicing, when transmitted to a collection agency) according to the amount of the debt in CHF: 37 (up to 19); 58 (up to 59); 145 (up to 399); 225 (up to 999); 285 (up to 1999); 385 (up to 2999); 575 (up to 4999); 685 (up to 6999); 825 (up to 9999); 1375 (up to 19999); 2600 (up to 49999); 6% of the debt (from 50000).<br \/>\r\n<br \/>\r\nChoice of law and venue clause:<br \/>\r\n<br \/>\r\n-Applicable law: Legal relations between the parties are exclusively governed by Swiss law, especially regarding rights related to the examination, treatment, and all services of Dr. Portier-Marret or his representative in the maxillofacial surgery office in La Riviera, Switzerland.<br \/>\r\n-Legal venue: The exclusive legal venue for all disputes related to the treatment or the aforementioned relationship with Dr. N. Portier is Lausanne, Switzerland. Dr. Portier-Marret has the right to appeal to other competent courts at the patient&#8217;s domicile.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_24.1' id='input_5_24_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_5_24\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_24_1' ><span class='gform-field-label__text'>Read and approved<\/span><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_24.2' value='Read and approved' class='gform_hidden' \/><input type='hidden' name='input_24.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_5_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Sans titre<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_5_25'><div class='gchoice gchoice_5_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='I have read and accept the &lt;a href=&quot;https:\/\/maxilloriviera.321dev.ch\/en\/privacy-policy\/&quot; target=&quot;_blank&quot;&gt;privacy policy&lt;\/a&gt;'  id='choice_5_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_25_1' id='label_5_25_1' class='gform-field-label gform-field-label--type-inline'>I have read and accept the <a href=\"https:\/\/maxilloriviera.321dev.ch\/en\/privacy-policy\/\" target=\"_blank\">privacy policy<\/a><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_27\" class=\"gfield gfield--type-captcha gfield--input-type-captcha 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_5_27'><span class='gform-field-label__text'>CAPTCHA<\/span><\/label><div id='input_5_27' class='ginput_container ginput_recaptcha' data-sitekey='6Lf8tigUAAAAAOlpA2BQObIFLgDKlytPP0Cl5eX_'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Send<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' 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After completing our electronic form of personal data and medical information (see online registration form below), make sure to click on the \u201csave\u201d button at the bottom of the page to automatically send us your completed secure form. [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1057,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1111","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.2 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Online medical questionnaire &#8211; MaxilloRiviera<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/maxilloriviera.ch\/en\/informations-patients\/questionnaire-medical-en-ligne\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Online medical questionnaire &#8211; MaxilloRiviera\" \/>\n<meta property=\"og:description\" content=\"Before your first medical consultation, you can pre-register online using our secure form for confidential patient data. 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