{"id":1003,"date":"2022-09-22T16:32:22","date_gmt":"2022-09-22T20:32:22","guid":{"rendered":"https:\/\/www.odq.wp.vortexdev.com\/?page_id=1003"},"modified":"2024-02-29T17:18:15","modified_gmt":"2024-02-29T21:18:15","slug":"formulaire-de-demande-denquete","status":"publish","type":"page","link":"https:\/\/www.odq.wp.vortexdev.com\/en\/formulaire-de-demande-denquete\/","title":{"rendered":"Formulaire de demande d&#8217;enqu\u00eate"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\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\/1003#gf_5' novalidate>\n                        <div class='gform_body gform-body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_5_135\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden gfield--date\"  data-field-class=\"gfield--date\" data-js-reload=\"field_5_135\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_5_135' >Date FIX REPEATER ISSUES<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_135' id='input_5_135' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_5_135_date_format gfield_description_5_135\" aria-invalid=\"false\" \/>\n                            <span id='input_5_135_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_135' class='gform_hidden' value='https:\/\/www.odq.wp.vortexdev.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_5_135'>ce champ et la pour temporairement fixer un souci de concurrence entre les script GF et ceux des repeaters custom<\/div><\/div><div id=\"field_5_137\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_hidden gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_137\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_5_137' >Code Postal FIX REAPEATER ISSUES<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_5_137' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_130\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_130\"><p>Il est en tout temps possible d&#8217;enregistrer votre progression avec le bouton &#8220;Enregistrer et continuer plus tard&#8221;.<\/p><\/div><div id=\"field_5_47\"  class=\"gfield gfield--width-full gfield_html_center_text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_47\"><img decoding=\"async\" src=\"\/wp-content\/uploads\/2022\/10\/1200px-Information_icon.svg_.png\" alt=\"Logo information\" width=\"61\" height=\"61\"\/>\n<h3>AVIS<\/h3>\n<h5>Si votre intention est d\u2019obtenir une compensation financi\u00e8re<\/h5>\n<h5>Veuillez noter que la transmission d\u2019une demande d\u2019enqu\u00eate au bureau du syndic, la tenue d\u2019une enqu\u00eate, puis le cas \u00e9ch\u00e9ant, le processus disciplinaire devant le conseil de discipline de notre ordre professionnel ne permettent pas d\u2019obtenir une compensation financi\u00e8re pour des dommages et inconv\u00e9nients qui seraient imputables \u00e0 une faute professionnelle commise par un dentiste.<\/h5>\n<h5>Si vous souhaitez obtenir une compensation financi\u00e8re, il est n\u00e9cessaire de vous adresser directement au dentiste et ce, sans attendre les conclusions de l\u2019enqu\u00eate. Si aucune entente \u00e0 votre satisfaction ne r\u00e9sulte de cette d\u00e9marche, vous devrez vous adresser aux tribunaux civils pour faire valoir vos droits.<\/h5>\n<h5>Nous vous invitons \u00e0 consulter un avocat pour vous conseiller et vous assister dans l\u2019exercice de vos droits. Vous pouvez \u00e9galement consulter le site internet du <a href=\"https:\/\/www.farpodq.org\/\" target=\"_blank\" rel=\"noopener\">Fonds d\u2019assurance-responsabilit\u00e9 professionnelle de l\u2019Ordre des dentistes du Qu\u00e9bec<\/a>.<\/h5><\/div><div id=\"field_5_133\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_133\"><h3>Demandeur d&#8217;enqu\u00eate<\/h3><\/div><fieldset id=\"field_5_1\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gfield--radio\"  data-field-class=\"gfield--radio\" data-js-reload=\"field_5_1\"><legend class='gfield_label'  >Je souhaite que mon identit\u00e9 demeure confidentielle<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_1'>\n\t\t\t<div class='gchoice gchoice_5_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Oui'  id='choice_5_1_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_1_0' id='label_5_1_0'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Non' checked='checked' id='choice_5_1_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_1_1' id='label_5_1_1'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_111\"  class=\"gfield gfield--width-full gfield_html_center_text gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_111\"><img decoding=\"async\" src=\"\/wp-content\/uploads\/2022\/10\/sign-warning-icon-png-7.png\" alt=\"Logo attention\" width=\"43\" height=\"43\"\/>\n<h3>ATTENTION<\/h3>\n<h5>Un signalement anonyme pourrait emp\u00eacher le bureau du syndic de mener une enqu\u00eate, compte tenu de l&#8217;importance de pouvoir v\u00e9rifier les all\u00e9gations et d&#8217;avoir des informations suffisantes pour justifier l&#8217;ouverture d&#8217;une enqu\u00eate.<\/h5><\/div><div id=\"field_5_85\"  class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_85\"><label class='gfield_label' for='input_5_85' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_5_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_86\"  class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_86\"><label class='gfield_label' for='input_5_86' >Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_5_86' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_4\"  class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--select\"  data-field-class=\"gfield--select\" data-js-reload=\"field_5_4\"><label class='gfield_label' for='input_5_4' >\u00c0 quel genre vous identifiez-vous?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_5_4' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Homme' >Homme<\/option><option value='Femme' >Femme<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><div id=\"field_5_87\"  class=\"gfield gfield--width-quarter vtx-width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_87\"><label class='gfield_label' for='input_5_87' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_5_87' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_88\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_88\"><label class='gfield_label' for='input_5_88' >Ville<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_5_88' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_90\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--select\"  data-field-class=\"gfield--select\" data-js-reload=\"field_5_90\"><label class='gfield_label' for='input_5_90' >Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_90' id='input_5_90' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/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='Yukon' >Yukon<\/option><\/select><\/div><\/div><div id=\"field_5_89\"  class=\"gfield gfield--width-quarter vtx-width-sixth gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_89\"><label class='gfield_label' for='input_5_89' >Code postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_5_89' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_75\"  class=\"gfield gfield--width-full vtx-width-two-thirds field_sublabel_below field_description_below gfield_visibility_visible gfield--repeater is-in-repeater\"  data-field-class=\"gfield--repeater is-in-repeater\" data-js-reload=\"field_5_75\"><div class='gfield_repeater_wrapper' data-max_items='10'><fieldset class='gfield_repeater gfield_repeater_container'>\n<legend class='gfield_label'>Num\u00e9ro de t\u00e9l\u00e9phone<\/legend><div class=\"gfield_repeater_items\"><div class='gfield_repeater_item'><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae3cd8'><label class='gfield_label' for='input_5_8-0' >Type<\/label><div class='ginput_container ginput_container_select'><select name='input_8[0]' id='input_5_8-0' class='large gfield_select'     aria-invalid=\"false\" ><option value='Domicile' >Domicile<\/option><option value='Travail' >Travail<\/option><option value='Cellulaire' selected='selected'>Cellulaire<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae3ed5'><label class='gfield_label' for='input_5_7-0' >Num\u00e9ro<\/label><div class='ginput_container ginput_container_text'><input name='input_7[0]' id='input_5_7-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_buttons'><button type='button' class='add_repeater_item  add_repeater_item_text' onclick='gformAddRepeaterItem(this)' onkeypress='gformAddRepeaterItem(this)'>Ajouter un num\u00e9ro de t\u00e9l\u00e9phone<\/button><button type='button' class='remove_repeater_item remove_repeater_item_text' onclick='if(confirm(\"Are you sure you want to remove this item?\")){gformDeleteRepeaterItem(this)};' onkeypress='gformDeleteRepeaterItem(this)' style='visibility:hidden;'>Retirer ce num\u00e9ro de t\u00e9l\u00e9phone<\/button><\/div><\/div><\/div><\/fieldset><\/div><\/div><div id=\"field_5_9\"  class=\"gfield gfield--width-full vtx-width-third field_sublabel_below field_description_below gfield_visibility_visible gfield--email\"  data-field-class=\"gfield--email\" data-js-reload=\"field_5_9\"><label class='gfield_label' for='input_5_9' >Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_5_9' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_5_10\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--radio\"  data-field-class=\"gfield--radio\" data-js-reload=\"field_5_10\"><legend class='gfield_label'  >\u00cates-vous le patient ayant \u00e9t\u00e9 l&#039;objet des traitements pour lesquels vous demandez une enqu\u00eate?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_10'>\n\t\t\t<div class='gchoice gchoice_5_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Oui'  id='choice_5_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Non'  id='choice_5_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_113\"  class=\"gfield gfield--width-full vtx-width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_113\"><label class='gfield_label' for='input_5_113' >Lien avec le patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_5_113' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_114\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_114\"><h5>Identification du patient<\/h5><\/div><div id=\"field_5_115\"  class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_115\"><label class='gfield_label' for='input_5_115' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_5_115' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_116\"  class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_116\"><label class='gfield_label' for='input_5_116' >Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_5_116' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_117\"  class=\"gfield gfield--width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--select\"  data-field-class=\"gfield--select\" data-js-reload=\"field_5_117\"><label class='gfield_label' for='input_5_117' >\u00c0 quel genre s&#039;identifie le patient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_117' id='input_5_117' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Homme' >Homme<\/option><option value='Femme' >Femme<\/option><option value='Autre' >Autre<\/option><\/select><\/div><\/div><fieldset id=\"field_5_118\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--radio\"  data-field-class=\"gfield--radio\" data-js-reload=\"field_5_118\"><legend class='gfield_label'  >L&#039;adresse est-elle diff\u00e9rente de celle du demandeur?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_118'>\n\t\t\t<div class='gchoice gchoice_5_118_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='Oui'  id='choice_5_118_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_118_0' id='label_5_118_0'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_118_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='Non'  id='choice_5_118_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_118_1' id='label_5_118_1'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_121\"  class=\"gfield gfield--width-quarter vtx-width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_121\"><label class='gfield_label' for='input_5_121' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_5_121' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_122\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_122\"><label class='gfield_label' for='input_5_122' >Ville<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_5_122' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_123\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--select\"  data-field-class=\"gfield--select\" data-js-reload=\"field_5_123\"><label class='gfield_label' for='input_5_123' >Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_123' id='input_5_123' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/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='Yukon' >Yukon<\/option><\/select><\/div><\/div><div id=\"field_5_124\"  class=\"gfield gfield--width-quarter vtx-width-sixth gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_124\"><label class='gfield_label' for='input_5_124' >Code postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_5_124' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_119\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--date\"  data-field-class=\"gfield--date\" data-js-reload=\"field_5_119\"><label class='gfield_label' for='input_5_119' >Date de naissance du patient<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_119' id='input_5_119' type='text' value='' class='datepicker ymd_dash datepicker_no_icon gdatepicker-no-icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_5_119_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_119_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_119' class='gform_hidden' value='https:\/\/www.odq.wp.vortexdev.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_127\"  class=\"gfield vtx-width-two-thirds field_sublabel_below field_description_below gfield_visibility_visible gfield--repeater is-in-repeater\"  data-field-class=\"gfield--repeater is-in-repeater\" data-js-reload=\"field_5_127\"><div class='gfield_repeater_wrapper' data-max_items='10'><fieldset class='gfield_repeater gfield_repeater_container'>\n<legend class='gfield_label'>Num\u00e9ro de t\u00e9l\u00e9phone du patient<\/legend><div class=\"gfield_repeater_items\"><div class='gfield_repeater_item'><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae64ff'><label class='gfield_label' for='input_5_125-0' >Type<\/label><div class='ginput_container ginput_container_select'><select name='input_125[0]' id='input_5_125-0' class='large gfield_select'     aria-invalid=\"false\" ><option value='Domicile' >Domicile<\/option><option value='Travail' >Travail<\/option><option value='Cellulaire' selected='selected'>Cellulaire<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae65a6'><label class='gfield_label' for='input_5_126-0' >Num\u00e9ro<\/label><div class='ginput_container ginput_container_text'><input name='input_126[0]' id='input_5_126-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_buttons'><button type='button' class='add_repeater_item  add_repeater_item_text' onclick='gformAddRepeaterItem(this)' onkeypress='gformAddRepeaterItem(this)'>Ajouter un num\u00e9ro de t\u00e9l\u00e9phone<\/button><button type='button' class='remove_repeater_item remove_repeater_item_text' onclick='if(confirm(\"Are you sure you want to remove this item?\")){gformDeleteRepeaterItem(this)};' onkeypress='gformDeleteRepeaterItem(this)' style='visibility:hidden;'>Retirer ce num\u00e9ro de t\u00e9l\u00e9phone<\/button><\/div><\/div><\/div><\/fieldset><\/div><\/div><div id=\"field_5_120\"  class=\"gfield gfield--width-full vtx-width-third field_sublabel_below field_description_below gfield_visibility_visible gfield--email\"  data-field-class=\"gfield--email\" data-js-reload=\"field_5_120\"><label class='gfield_label' for='input_5_120' >Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_120' id='input_5_120' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_112\"  class=\"gfield gfield--width-full vtx-width-third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--date\"  data-field-class=\"gfield--date\" data-js-reload=\"field_5_112\"><label class='gfield_label' for='input_5_112' >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_112' id='input_5_112' type='text' value='' class='datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_5_112_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_112_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_112' class='gform_hidden' value='https:\/\/www.odq.wp.vortexdev.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_11\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_11\"><h3>Dentiste(s) vis\u00e9(s) par l&#8217;enqu\u00eate<\/h3>\n<h5>Il est possible qu&#8217;une enqu\u00eate vise plusieurs dentistes.\nDans ce cas, vous pouvez ajouter autant de dentistes que souhait\u00e9 avec l&#8217;option : + Ajouter un autre dentiste<\/h5><\/div><div id=\"field_5_74\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gfield--repeater is-in-repeater\"  data-field-class=\"gfield--repeater is-in-repeater\" data-js-reload=\"field_5_74\"><div class='gfield_repeater_wrapper' data-max_items='10'><fieldset class='gfield_repeater gfield_repeater_container'>\n<legend class='gfield_label'>Dentiste(s) vis\u00e9(s)<\/legend><div class=\"gfield_repeater_items\"><div class='gfield_repeater_item'><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae6b53'><label class='gfield_label' for='input_5_12-0' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12[0]' id='input_5_12-0' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae6bff'><label class='gfield_label' for='input_5_13-0' >Clinique dentaire\/\u200b\u00e9tablissement o\u00f9 les services ont \u00e9t\u00e9 rendus<\/label><div class='ginput_container ginput_container_text'><input name='input_13[0]' id='input_5_13-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae6c79'><label class='gfield_label' for='input_5_91-0' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_91[0]' id='input_5_91-0' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aae6cc9'><label class='gfield_label' for='input_5_92-0' >Ville<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_92[0]' id='input_5_92-0' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aae6d12'><label class='gfield_label' for='input_5_93-0' >Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_93[0]' id='input_5_93-0' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/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='Yukon' >Yukon<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-sixth' data-cell-id='69e4a4aae6da5'><label class='gfield_label' for='input_5_94-0' >Code postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_94[0]' id='input_5_94-0' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae6e05'><label class='gfield_label' for='input_5_16-0' >Num\u00e9ro de t\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_text'><input name='input_16[0]' id='input_5_16-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae6e51'><label class='gfield_label' for='input_5_73-0' >Autre num\u00e9ro de t\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_text'><input name='input_73[0]' id='input_5_73-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae6e9b'><label class='gfield_label' for='input_5_17-0' >Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17[0]' id='input_5_17-0' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div class='gfield_repeater_buttons'><button type='button' class='add_repeater_item  add_repeater_item_text' onclick='gformAddRepeaterItem(this)' onkeypress='gformAddRepeaterItem(this)'>Ajouter un autre dentiste<\/button><button type='button' class='remove_repeater_item remove_repeater_item_text' onclick='if(confirm(\"Are you sure you want to remove this item?\")){gformDeleteRepeaterItem(this)};' onkeypress='gformDeleteRepeaterItem(this)' style='visibility:hidden;'>Retirer ce dentiste<\/button><\/div><\/div><\/div><\/fieldset><\/div><\/div><div id=\"field_5_18\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_18\"><h3>Informations n\u00e9cessaires au traitement de la demande d&#8217;enqu\u00eate<\/h3>\n<h5>1. Avez-vous consult\u00e9 d&#8217;autres personnes ou d\u2019autres professionnels relativement aux faits all\u00e9gu\u00e9s dans cette demande d&#8217;enqu\u00eate? <span class=\"gfield_required\">*<\/span><\/h5><\/div><fieldset id=\"field_5_83\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible gfield--radio\"  data-field-class=\"gfield--radio\" data-js-reload=\"field_5_83\"><legend class='gfield_label'  >Avez-vous consult\u00e9 d&#039;autres personnes ou d\u2019autres professionnels relativement aux faits all\u00e9gu\u00e9s dans cette demande d&#039;enqu\u00eate?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_83'>\n\t\t\t<div class='gchoice gchoice_5_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Oui'  id='choice_5_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_83_0' id='label_5_83_0'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Non'  id='choice_5_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_83_1' id='label_5_83_1'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_84\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_84\"><h5>Veuillez indiquer leurs noms et leurs coordonn\u00e9es.<\/h5><\/div><div id=\"field_5_79\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gfield--repeater is-in-repeater\"  data-field-class=\"gfield--repeater is-in-repeater\" data-js-reload=\"field_5_79\"><div class='gfield_repeater_wrapper' data-max_items='10'><fieldset class='gfield_repeater gfield_repeater_container'>\n<legend class='gfield_label'>Professionnels consult\u00e9s<\/legend><div class=\"gfield_repeater_items\"><div class='gfield_repeater_item'><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae885c'><label class='gfield_label' for='input_5_19-0' >Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19[0]' id='input_5_19-0' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Dentiste' >Dentiste<\/option><option value='Denturologiste' >Denturologiste<\/option><option value='Hygi\u00e9niste dentaire' >Hygi\u00e9niste dentaire<\/option><option value='M\u00e9decin' >M\u00e9decin<\/option><option value='M\u00e9decin sp\u00e9cialiste' >M\u00e9decin sp\u00e9cialiste<\/option><option value='Pharmacien' >Pharmacien<\/option><option value='Autre professionnel de la sant\u00e9' >Autre professionnel de la sant\u00e9<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half vtx-gfield-hidden' data-cell-id='69e4a4aae8a75'><label class='gfield_label' for='input_5_129-0' >Veuillez pr\u00e9ciser<\/label><div class='ginput_container ginput_container_text'><input name='input_129[0]' id='input_5_129-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae8bb2'><label class='gfield_label' for='input_5_20-0' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20[0]' id='input_5_20-0' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aae8cb5'><label class='gfield_label' for='input_5_21-0' >Nom de la clinique dentaire ou de l&#039;\u00e9tablissement<\/label><div class='ginput_container ginput_container_text'><input name='input_21[0]' id='input_5_21-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae8fb9'><label class='gfield_label' for='input_5_95-0' >Adresse<\/label><div class='ginput_container ginput_container_text'><input name='input_95[0]' id='input_5_95-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aae90d3'><label class='gfield_label' for='input_5_96-0' >Ville<\/label><div class='ginput_container ginput_container_text'><input name='input_96[0]' id='input_5_96-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aae921b'><label class='gfield_label' for='input_5_97-0' >Province<\/label><div class='ginput_container ginput_container_select'><select name='input_97[0]' id='input_5_97-0' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/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='Yukon' >Yukon<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-sixth' data-cell-id='69e4a4aae9423'><label class='gfield_label' for='input_5_98-0' >Code postal<\/label><div class='ginput_container ginput_container_text'><input name='input_98[0]' id='input_5_98-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae9575'><label class='gfield_label' for='input_5_25-0' >Num\u00e9ro de t\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_text'><input name='input_25[0]' id='input_5_25-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae96f7'><label class='gfield_label' for='input_5_76-0' >Autre num\u00e9ro de t\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_text'><input name='input_76[0]' id='input_5_76-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aae9899'><label class='gfield_label' for='input_5_26-0' >Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_26[0]' id='input_5_26-0' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div class='gfield_repeater_buttons'><button type='button' class='add_repeater_item  add_repeater_item_text' onclick='gformAddRepeaterItem(this)' onkeypress='gformAddRepeaterItem(this)'>Ajouter un autre professionnel<\/button><button type='button' class='remove_repeater_item remove_repeater_item_text' onclick='if(confirm(\"Are you sure you want to remove this item?\")){gformDeleteRepeaterItem(this)};' onkeypress='gformDeleteRepeaterItem(this)' style='visibility:hidden;'>Retirer ce professionnel<\/button><\/div><\/div><\/div><\/fieldset><\/div><\/div><div id=\"field_5_27\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_27\"><h5>2. Des personnes peuvent-elles t\u00e9moigner de certains faits relatifs \u00e0 cette demande d&#8217;enqu\u00eate? <span class=\"gfield_required\">*<\/span><\/h5><\/div><fieldset id=\"field_5_81\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible gfield--radio\"  data-field-class=\"gfield--radio\" data-js-reload=\"field_5_81\"><legend class='gfield_label'  >Des personnes peuvent-elles t\u00e9moigner de certains faits relatifs \u00e0 cette demande d&#039;enqu\u00eate?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_81'>\n\t\t\t<div class='gchoice gchoice_5_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Oui'  id='choice_5_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_81_0' id='label_5_81_0'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Non'  id='choice_5_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_81_1' id='label_5_81_1'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_82\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_82\"><h5>Veuillez indiquer leurs noms et leurs coordonn\u00e9es.<\/h5><\/div><div id=\"field_5_78\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gfield--repeater is-in-repeater\"  data-field-class=\"gfield--repeater is-in-repeater\" data-js-reload=\"field_5_78\"><div class='gfield_repeater_wrapper' data-max_items='10'><fieldset class='gfield_repeater gfield_repeater_container'>\n<legend class='gfield_label'>Personnes t\u00e9moins<\/legend><div class=\"gfield_repeater_items\"><div class='gfield_repeater_item'><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aaeb82e'><label class='gfield_label' for='input_5_28-0' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28[0]' id='input_5_28-0' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aaeb906'><label class='gfield_label' for='input_5_30-0' >Lien avec patient<\/label><div class='ginput_container ginput_container_text'><input name='input_30[0]' id='input_5_30-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaeb988'><label class='gfield_label' for='input_5_99-0' >Adresse<\/label><div class='ginput_container ginput_container_text'><input name='input_99[0]' id='input_5_99-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aaeb9f1'><label class='gfield_label' for='input_5_100-0' >Ville<\/label><div class='ginput_container ginput_container_text'><input name='input_100[0]' id='input_5_100-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aaeba75'><label class='gfield_label' for='input_5_101-0' >Province<\/label><div class='ginput_container ginput_container_select'><select name='input_101[0]' id='input_5_101-0' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/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='Yukon' >Yukon<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-sixth' data-cell-id='69e4a4aaebb5b'><label class='gfield_label' for='input_5_102-0' >Code postal<\/label><div class='ginput_container ginput_container_text'><input name='input_102[0]' id='input_5_102-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaebbd5'><label class='gfield_label' for='input_5_33-0' >Num\u00e9ro de t\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_text'><input name='input_33[0]' id='input_5_33-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaebd8f'><label class='gfield_label' for='input_5_77-0' >Autre num\u00e9ro de t\u00e9l\u00e9phone<\/label><div class='ginput_container ginput_container_text'><input name='input_77[0]' id='input_5_77-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaebea1'><label class='gfield_label' for='input_5_34-0' >Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_34[0]' id='input_5_34-0' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div class='gfield_repeater_buttons'><button type='button' class='add_repeater_item  add_repeater_item_text' onclick='gformAddRepeaterItem(this)' onkeypress='gformAddRepeaterItem(this)'>Ajouter une autre personne<\/button><button type='button' class='remove_repeater_item remove_repeater_item_text' onclick='if(confirm(\"Are you sure you want to remove this item?\")){gformDeleteRepeaterItem(this)};' onkeypress='gformDeleteRepeaterItem(this)' style='visibility:hidden;'>Retirer cette personne<\/button><\/div><\/div><\/div><\/fieldset><\/div><\/div><div id=\"field_5_35\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_35\"><h5>3. Au cours de l\u2019enqu\u00eate, il pourrait \u00eatre n\u00e9cessaire d\u2019obtenir des renseignements de votre ancien dentiste traitant.<br>\nVeuillez indiquez son nom et ses coordonn\u00e9es.<h5><\/div><div id=\"field_5_36\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_36\"><label class='gfield_label' for='input_5_36' >Nom<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_5_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_37\"  class=\"gfield gfield--width-half field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_37\"><label class='gfield_label' for='input_5_37' >Nom de la clinique dentaire ou de l&#039;\u00e9tablissement<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_103\"  class=\"gfield gfield--width-quarter vtx-width-third field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_103\"><label class='gfield_label' for='input_5_103' >Adresse<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_5_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_104\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_104\"><label class='gfield_label' for='input_5_104' >Ville<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_5_104' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_105\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible gfield--select\"  data-field-class=\"gfield--select\" data-js-reload=\"field_5_105\"><label class='gfield_label' for='input_5_105' >Province<\/label><div class='ginput_container ginput_container_select'><select name='input_105' id='input_5_105' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/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='Yukon' >Yukon<\/option><\/select><\/div><\/div><div id=\"field_5_106\"  class=\"gfield gfield--width-quarter vtx-width-sixth field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_106\"><label class='gfield_label' for='input_5_106' >Code postal<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_5_106' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_39\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible gfield--select\"  data-field-class=\"gfield--select\" data-js-reload=\"field_5_39\"><label class='gfield_label' for='input_5_39' >Type<\/label><div class='ginput_container ginput_container_select'><select name='input_39' id='input_5_39' class='large gfield_select'     aria-invalid=\"false\" ><option value='Domicile' >Domicile<\/option><option value='Travail' >Travail<\/option><option value='Cellulaire' selected='selected'>Cellulaire<\/option><\/select><\/div><\/div><div id=\"field_5_40\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_40\"><label class='gfield_label' for='input_5_40' >Num\u00e9ro<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_5_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_41\"  class=\"gfield gfield--width-third field_sublabel_below field_description_below gfield_visibility_visible gfield--email\"  data-field-class=\"gfield--email\" data-js-reload=\"field_5_41\"><label class='gfield_label' for='input_5_41' >Adresse courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_41' id='input_5_41' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_42\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_42\"><h3>D\u00e9claration du demandeur d&#8217;enqu\u00eate<\/h3>\n<h5>Veuillez d\u00e9crire les faits et les motifs de votre demande d\u2019enqu\u00eate, notamment une description des \u00e9v\u00e9nements survenus et des traitements re\u00e7us, ainsi que les fautes reproch\u00e9es au dentiste, en pr\u00e9cisant les dates, dans l&#8217;ordre o\u00f9 ceux-ci se sont produits.<\/h5>\n<h5>Joignez les documents pertinents, s\u2019il y a lieu.<\/h5><\/div><div id=\"field_5_43\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below hidden_label gfield_visibility_visible gfield--textarea\"  data-field-class=\"gfield--textarea\" data-js-reload=\"field_5_43\"><label class='gfield_label' for='input_5_43' >Veuillez d\u00e9crire les faits et les motifs de votre demande d\u2019enqu\u00eate<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_5_43' class='textarea large'    placeholder='Veuillez utiliser autant de lignes (pages) que n\u00e9cessaires.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_44\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible gfield--fileupload\"  data-field-class=\"gfield--fileupload\" data-js-reload=\"field_5_44\"><label class='gfield_label' for='gform_browse_button_5_44' >Document(s) pertinent(s)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_44' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_44&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_44&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_44&quot;,&quot;filelist&quot;:&quot;gform_preview_5_44&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.odq.wp.vortexdev.com\\\/?gf_page=761728d9fd6347a&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.odq.wp.vortexdev.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.odq.wp.vortexdev.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;33554432b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:5,&quot;field_id&quot;:44},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_44&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_5_44' class='gform_drop_area'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_5_44' class='button gform_button_select_files' aria-describedby=\"gfield_upload_rules_5_44\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gform_fileupload_rules' id='gfield_upload_rules_5_44'>Max. file size: 32 MB.<\/span><ul class='validation_message validation_message--hidden-on-empty gfield_validation_message gform-ul-reset' id='gform_multifile_messages_5_44'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_5_44'><\/div><\/div><div id=\"field_5_45\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_45\"><h3>Vos attentes<\/h3><\/div><div id=\"field_5_46\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below hidden_label gfield_visibility_visible gfield--textarea\"  data-field-class=\"gfield--textarea\" data-js-reload=\"field_5_46\"><label class='gfield_label' for='input_5_46' >Quelles sont vos attentes \u00e0 la suite de votre demande?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_5_46' class='textarea medium'    placeholder='Quelles sont vos attentes \u00e0 la suite de votre demande?'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_48\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_48\"><h3>Autorisation de communiquer mon dossier m\u00e9dical ou hospitalier<\/h3>\n<h5>Si vous avez \u00e9t\u00e9 hospitalis\u00e9 ou avez consult\u00e9 un m\u00e9decin relativement \u00e0 votre \u00e9tat, veuillez remplir et signer l\u2019autorisation suivante :<\/h5><\/div><div id=\"field_5_80\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible gfield--repeater is-in-repeater\"  data-field-class=\"gfield--repeater is-in-repeater\" data-js-reload=\"field_5_80\"><div class='gfield_repeater_wrapper' data-max_items='10'><fieldset class='gfield_repeater gfield_repeater_container'>\n<legend class='gfield_label'>Dossier(s)<\/legend><div class=\"gfield_repeater_items\"><div class='gfield_repeater_item'><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaed8a9'><label class='gfield_label' for='input_5_49-0' >Nom et pr\u00e9nom \u00e0 la naissance<\/label><div class='ginput_container ginput_container_text'><input name='input_49[0]' id='input_5_49-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaeda0e'><label class='gfield_label' for='input_5_50-0' >Nom actuellement utilis\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_50[0]' id='input_5_50-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaedac0'><label class='gfield_label' for='input_5_52-0' >Date de naissance<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52[0]' id='input_5_52-0' type='text' value='' class='datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_5_52_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_52_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_52' class='gform_hidden' value='https:\/\/www.odq.wp.vortexdev.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div class='gfield_repeater_cell repeater-field--width-third' data-cell-id='69e4a4aaedce2'><label class='gfield_label' for='input_5_107-0' >Adresse actuelle de l&#039;usager<\/label><div class='ginput_container ginput_container_text'><input name='input_107[0]' id='input_5_107-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aaeddf4'><label class='gfield_label' for='input_5_108-0' >Ville<\/label><div class='ginput_container ginput_container_text'><input name='input_108[0]' id='input_5_108-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aaede9a'><label class='gfield_label' for='input_5_109-0' >Province<\/label><div class='ginput_container ginput_container_select'><select name='input_109[0]' id='input_5_109-0' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='\u00cele-du-Prince-\u00c9douard' >\u00cele-du-Prince-\u00c9douard<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/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='Yukon' >Yukon<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-sixth' data-cell-id='69e4a4aaee066'><label class='gfield_label' for='input_5_110-0' >Code postal<\/label><div class='ginput_container ginput_container_text'><input name='input_110[0]' id='input_5_110-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aaee112'><label class='gfield_label' for='input_5_54-0' >Je soussign\u00e9-e,<\/label><div class='ginput_container ginput_container_text'><input name='input_54[0]' id='input_5_54-0' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_54\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_5_54'>Pr\u00e9nom et Nom en lettre moul\u00e9es<\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aaee1fd'><label class='gfield_label' for='input_5_55-0' >En ma qualit\u00e9 de<\/label><div class='ginput_container ginput_container_select'><select name='input_55[0]' id='input_5_55-0' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Veuillez choisir&#8230;<\/option><option value='Usager' >Usager<\/option><option value='Personne l\u00e9galement responsable' >Personne l\u00e9galement responsable<\/option><\/select><\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aaee2e1'><label class='gfield_label' for='input_5_56-0' >J&#039;autorise le Dr<\/label><div class='ginput_container ginput_container_text'><input name='input_56[0]' id='input_5_56-0' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_56\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_5_56'>Pr\u00e9nom et Nom du m\u00e9decin en lettres moul\u00e9es<\/div><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aaee3f7'><label class='gfield_label' for='input_5_57-0' >J&#039;autorise le centre hospitalier<\/label><div class='ginput_container ginput_container_text'><input name='input_57[0]' id='input_5_57-0' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div class='gfield_repeater_cell ' data-cell-id='69e4a4aaee4ab'><p>\u00e0 faire parvenir au syndic de l\u2019Ordre des dentistes du Qu\u00e9bec, une copie de mon dossier m\u00e9dical, pour les soins ou services re\u00e7us, se rapportant \u00e0 la p\u00e9riode qui sera sp\u00e9cifi\u00e9e par le syndic dans sa demande.<\/p><\/div><div class='gfield_repeater_cell repeater-field--width-half' data-cell-id='69e4a4aaee51f'><label class='gfield_label' for='input_5_59-0' >Signature dossier<\/label><div class='ginput_container ginput_container_text'><input name='input_59[0]' id='input_5_59-0' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_59\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_5_59'>Signataire : usager ou personne autoris\u00e9e<\/div><\/div><div class='gfield_repeater_cell repeater-field--width-quarter' data-cell-id='69e4a4aaee5d2'><label class='gfield_label' for='input_5_60-0' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_60[0]' id='input_5_60-0' type='text' value='2026-04-19' class='datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_5_60_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_60_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_60' class='gform_hidden' value='https:\/\/www.odq.wp.vortexdev.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div class='gfield_repeater_buttons'><button type='button' class='add_repeater_item  add_repeater_item_text' onclick='gformAddRepeaterItem(this)' onkeypress='gformAddRepeaterItem(this)'>Ajouter un autre dossier<\/button><button type='button' class='remove_repeater_item remove_repeater_item_text' onclick='if(confirm(\"Are you sure you want to remove this item?\")){gformDeleteRepeaterItem(this)};' onkeypress='gformDeleteRepeaterItem(this)' style='visibility:hidden;'>Retirer ce dossier<\/button><\/div><\/div><\/div><\/fieldset><\/div><\/div><div id=\"field_5_61\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_61\"><h3>Confirmation et suivi<\/h3><\/div><fieldset id=\"field_5_64\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible gfield--checkbox gfield--has-multiple-inputs\"  data-field-class=\"gfield--checkbox gfield--has-multiple-inputs\" data-js-reload=\"field_5_64\"><legend class='gfield_label gfield_label_before_complex'  >Confirmation et suivi<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_64'><div class='gchoice gchoice_5_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='Je confirme que les renseignements fournis sont v\u00e9ridiques au meilleur de ma connaissance.'  id='choice_5_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_64_1' id='label_5_64_1'>Je confirme que les renseignements fournis sont v\u00e9ridiques au meilleur de ma connaissance.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_64_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.2' type='checkbox'  value='J\u2019accepte qu\u2019une copie de ma d\u00e9claration ou un r\u00e9sum\u00e9 de celle-ci soit transmise au(x) dentiste(s) vis\u00e9(s) aux fins de l\u2019enqu\u00eate demand\u00e9e.'  id='choice_5_64_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_64_2' id='label_5_64_2'>J\u2019accepte qu\u2019une copie de ma d\u00e9claration ou un r\u00e9sum\u00e9 de celle-ci soit transmise au(x) dentiste(s) vis\u00e9(s) aux fins de l\u2019enqu\u00eate demand\u00e9e.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_65\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_65\"><address><hr style=\"margin: 1rem 0;\"><\/address><address><strong style=\"font-style: italic;\">Nous d\u00e9sirons vous aviser qu\u2019il est possible, si nous le jugeons n\u00e9cessaire, que nous fassions parvenir au dentiste vis\u00e9 par la demande d&#8217;enqu\u00eate, une copie de votre d\u00e9claration du demandeur ou un r\u00e9sum\u00e9 de celle-ci, afin de lui permettre de fournir sa version des faits et de bien comprendre la port\u00e9e de votre demande.<\/strong><\/address><address style=\"margin: 0;\"><hr style=\"margin: 1rem 0;\"><\/address><\/div><fieldset id=\"field_5_131\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible gfield--checkbox gfield--has-multiple-inputs\"  data-field-class=\"gfield--checkbox gfield--has-multiple-inputs\" data-js-reload=\"field_5_131\"><legend class='gfield_label gfield_label_before_complex'  >Consentement<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_131'><div class='gchoice gchoice_5_131_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_131.1' type='checkbox'  value='Je suis conscient.e que ma collaboration \u00e0 l&#039;enqu\u00eate et, comme t\u00e9moin dans l&#039;\u00e9ventualit\u00e9 du d\u00e9p\u00f4t d&#039;une plainte disciplinaire contre le dentiste vis\u00e9 par l&#039;enqu\u00eate devant le conseil de discipline le l&#039;Ordre des dentistes du Qu\u00e9bec, est importante et requise et je confirme que le bureau du syndic pourra compter sur mon enti\u00e8re collaboration.'  id='choice_5_131_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_131_1' id='label_5_131_1'>Je suis conscient.e que ma collaboration \u00e0 l&#8217;enqu\u00eate et, comme t\u00e9moin dans l&#8217;\u00e9ventualit\u00e9 du d\u00e9p\u00f4t d&#8217;une plainte disciplinaire contre le dentiste vis\u00e9 par l&#8217;enqu\u00eate devant le conseil de discipline le l&#8217;Ordre des dentistes du Qu\u00e9bec, est importante et requise et je confirme que le bureau du syndic pourra compter sur mon enti\u00e8re collaboration.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_67\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--radio\"  data-field-class=\"gfield--radio\" data-js-reload=\"field_5_67\"><legend class='gfield_label'  >Suivi de la progression de l&#039;enqu\u00eate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_67'>\n\t\t\t<div class='gchoice gchoice_5_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Je d\u00e9sire \u00eatre inform\u00e9 de la progression de l\u2019enqu\u00eate et de sa conclusion.'  id='choice_5_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_0' id='label_5_67_0'>Je d\u00e9sire \u00eatre inform\u00e9 de la progression de l\u2019enqu\u00eate et de sa conclusion.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Je d\u00e9sire \u00eatre inform\u00e9 de la conclusion de l\u2019enqu\u00eate seulement.'  id='choice_5_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_1' id='label_5_67_1'>Je d\u00e9sire \u00eatre inform\u00e9 de la conclusion de l\u2019enqu\u00eate seulement.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_67_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Je ne d\u00e9sire pas \u00eatre inform\u00e9.'  id='choice_5_67_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_67_2' id='label_5_67_2'>Je ne d\u00e9sire pas \u00eatre inform\u00e9.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_68\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--radio\"  data-field-class=\"gfield--radio\" data-js-reload=\"field_5_68\"><legend class='gfield_label'  >Par quel moyen de communication pr\u00e9f\u00e9rez-vous \u00eatre contact\u00e9?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_68'>\n\t\t\t<div class='gchoice gchoice_5_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Par courriel'  id='choice_5_68_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_0' id='label_5_68_0'>Par courriel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Par la poste'  id='choice_5_68_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_68_1' id='label_5_68_1'>Par la poste<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_69\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible gfield--checkbox gfield--has-multiple-inputs\"  data-field-class=\"gfield--checkbox gfield--has-multiple-inputs\" data-js-reload=\"field_5_69\"><legend class='gfield_label gfield_label_before_complex'  >Recevoir une copie de mon formulaire compl\u00e9t\u00e9<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_5_69'><div class='gchoice gchoice_5_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Je souhaite recevoir une copie de mon formulaire compl\u00e9t\u00e9 \u00e0 l\u2019adresse courriel indiqu\u00e9 ci-dessus.'  id='choice_5_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_69_1' id='label_5_69_1'>Je souhaite recevoir une copie de mon formulaire compl\u00e9t\u00e9 \u00e0 l\u2019adresse courriel indiqu\u00e9 ci-dessus.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_132\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible gfield--html\"  data-field-class=\"gfield--html\" data-js-reload=\"field_5_132\"><br>\n<br><\/div><div id=\"field_5_70\"  class=\"gfield gfield--width-two-thirds gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible gfield--text\"  data-field-class=\"gfield--text\" data-js-reload=\"field_5_70\"><label class='gfield_label' for='input_5_70' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_5_70' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_5_71\"  class=\"gfield gfield--width-third vtx-width-quarter field_sublabel_below field_description_below gfield_visibility_visible gfield--date\"  data-field-class=\"gfield--date\" data-js-reload=\"field_5_71\"><label class='gfield_label' for='input_5_71' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_71' id='input_5_71' type='text' value='2026-04-19' class='datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='yyyy-mm-dd' aria-describedby=\"input_5_71_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_71_date_format' 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