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  1. <form action="/en/referring-doctors/#wpcf7-f156-p298-o1" method="post" class="wpcf7-form" enctype="multipart/form-data" novalidate="novalidate">
  2. <div style="display: none;">
  3. <input type="hidden" name="_wpcf7" value="156">
  4. <input type="hidden" name="_wpcf7_version" value="5.0.3">
  5. <input type="hidden" name="_wpcf7_locale" value="en_US">
  6. <input type="hidden" name="_wpcf7_unit_tag" value="wpcf7-f156-p298-o1">
  7. <input type="hidden" name="_wpcf7_container_post" value="298">
  8. </div>
  9. <div class="row">
  10. <div class="form-group col-md-6">
  11. <p>Les champs marqués d’un astérisque (<span class="blue">*</span>) sont obligatoires.</p>
  12. <p><i>Fields marked with an asterisk  (<span class="blue">*</span>) are required.</i></p>
  13. </div>
  14. <div class="form-group col-md-6">
  15. <span class="wpcf7-form-control-wrap DateDate"><input type="text" name="DateDate" value="" size="40" class="wpcf7-form-control wpcf7-date wpcf7-validates-as-required w3-input w3-border hasDatepicker" aria-required="true" placeholder="Date / Date *" id="dp1550486044966"> </span>
  16. </div>
  17. <div class="form-group col-md-12">
  18. <hr>
  19. </div>
  20. <p><!-- Dr --></p>
  21. <div class="col-md-6">
  22. <p class="font-18 text-uppercase">Dentiste référent / <i>Referring dentist</i></p>
  23. <div class="form-group">
  24. <span class="wpcf7-form-control-wrap referringDr"><input type="text" name="referringDr" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Dr. *"></span>
  25. </div>
  26. <div class="form-group">
  27. <span class="wpcf7-form-control-wrap referringTlphonePhone"><input type="tel" name="referringTlphonePhone" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Téléphone / Phone *"></span>
  28. </div>
  29. <div class="form-group">
  30. <span class="wpcf7-form-control-wrap referringCourrielEmail"><input type="email" name="referringCourrielEmail" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email w3-input w3-border" aria-invalid="false" placeholder="Courriel / Email"></span>
  31. </div>
  32. <div class="form-group">
  33. <span class="wpcf7-form-control-wrap referringAdresseAddress"><input type="text" name="referringAdresseAddress" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Adresse / Address *"></span>
  34. </div>
  35. <div class="form-group">
  36. <span class="wpcf7-form-control-wrap referringProvinces"><select name="referringProvinces" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required w3-select w3-border" aria-required="true" aria-invalid="false"><option value="Quebec">Quebec</option><option value="Ontario">Ontario</option><option value="British Columbia">British Columbia</option><option value="Alberta">Alberta</option><option value="Manitoba">Manitoba</option><option value="Saskatchewan">Saskatchewan</option><option value="Nova Scotia">Nova Scotia</option><option value="New Brunswick">New Brunswick</option><option value="Newfoundland and Labrador">Newfoundland and Labrador</option><option value="Prince Edward Island">Prince Edward Island</option><option value="Northwest Territories">Northwest Territories</option><option value="Yukon">Yukon</option><option value="Nunavut">Nunavut</option></select></span>
  37. </div>
  38. <div class="form-group">
  39. <span class="wpcf7-form-control-wrap referringVilleCity"><input type="text" name="referringVilleCity" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Ville / City *"></span>
  40. </div>
  41. <div class="form-group">
  42. <span class="wpcf7-form-control-wrap referringCodepostaleZipCode"><input type="text" name="referringCodepostaleZipCode" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Code postal / Postal code *"></span>
  43. </div>
  44. </div>
  45. <p><!-- Patient --></p>
  46. <div class="col-md-6">
  47. <p class="font-18 text-uppercase">patient</p>
  48. <div class="form-group">
  49. <span class="wpcf7-form-control-wrap patientgender"><span class="wpcf7-form-control wpcf7-radio w3-radio"><span class="wpcf7-list-item first"><input type="radio" name="patientgender" value="M. / Mr." checked="checked"><span class="wpcf7-list-item-label">M. / Mr.</span></span><span class="wpcf7-list-item last"><input type="radio" name="patientgender" value="Mme / Ms."><span class="wpcf7-list-item-label">Mme / Ms.</span></span></span></span>
  50. </div>
  51. <div class="form-group">
  52. <span class="wpcf7-form-control-wrap patientPrnomFirstName"><input type="text" name="patientPrnomFirstName" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Prénom / First Name *"></span>
  53. </div>
  54. <div class="form-group">
  55. <span class="wpcf7-form-control-wrap patientNomLastName"><input type="text" name="patientNomLastName" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Nom / Last Name *"></span>
  56. </div>
  57. <div class="form-group">
  58. <span class="wpcf7-form-control-wrap patientTlphone1Phone1"><input type="text" name="patientTlphone1Phone1" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Téléphone 1 / Phone 1 *"></span>
  59. </div>
  60. <div class="form-group">
  61. <span class="wpcf7-form-control-wrap patientTlphone2Phone2"><input type="text" name="patientTlphone2Phone2" value="" size="40" class="wpcf7-form-control wpcf7-text w3-input w3-border" aria-invalid="false" placeholder="Téléphone 2 / Phone 2"></span>
  62. </div>
  63. <div class="form-group">
  64. <span class="wpcf7-form-control-wrap patientCourrielEmail"><input type="email" name="patientCourrielEmail" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email w3-input w3-border" aria-invalid="false" placeholder="Courriel / Email"></span>
  65. </div>
  66. <div class="form-group">
  67. <span class="wpcf7-form-control-wrap patientDatedenaissanceDateofbirth"><input type="text" name="patientDatedenaissanceDateofbirth" value="" size="40" class="wpcf7-form-control wpcf7-date wpcf7-validates-as-required w3-input w3-border hasDatepicker" aria-required="true" placeholder="Date de naissance / Date of birth (DD-MM-YYYY) *" id="dp1550486044967"> </span>
  68. </div>
  69. </div>
  70. <div class="form-group col-md-12">
  71. <hr>
  72. </div>
  73. <div class="col-md-6">
  74. <p class="font-18 text-uppercase">Dent(s) / <i>Tooth (teeth)</i>   </p>
  75. <div class="form-group">
  76. <span class="wpcf7-form-control-wrap DENTSTOOTHTEETH"><input type="text" name="DENTSTOOTHTEETH" value="" size="40" class="wpcf7-form-control wpcf7-text w3-input w3-border" aria-invalid="false"></span>
  77. </div>
  78. <div class="form-group">
  79. <span class="wpcf7-form-control-wrap treatments"><select name="treatments" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required w3-select w3-border" aria-required="true" aria-invalid="false"><option value="Traitement d'urgence / Emergency treatment">Traitement d'urgence / Emergency treatment</option><option value="Scan 3D/ 3D Scan">Scan 3D/ 3D Scan</option><option value="Consultation diagnostique / Diagnosis">Consultation diagnostique / Diagnosis</option><option value="Traitement de canal / Root canal treatment">Traitement de canal / Root canal treatment</option><option value="Retraitement / Retreatment">Retraitement / Retreatment</option><option value="Chirurgie apicale / Apical surgery">Chirurgie apicale / Apical surgery</option><option value="Apexification ou regénération / Apexification or regeneration">Apexification ou regénération / Apexification or regeneration</option><option value="Réimplantation intentionnelle / Intentional replantation">Réimplantation intentionnelle / Intentional replantation</option><option value="Blanchiment interne / Internal bleaching">Blanchiment interne / Internal bleaching</option><option value="Gestion des traumas/ Trauma management">Gestion des traumas/ Trauma management</option><option value="Résorption interne ou externe/ Internal or External Resorption">Résorption interne ou externe/ Internal or External Resorption</option></select></span>
  80. </div>
  81. </div>
  82. <div class="col-md-6">
  83. <p class="font-18 text-uppercase">Restaurer avec / <i>Restore with</i>  </p>
  84. <div class="form-group">
  85. <span class="wpcf7-form-control-wrap RESTAURERAVECRESTOREWITH"><span class="wpcf7-form-control wpcf7-radio w3-radio fullo"><span class="wpcf7-list-item first"><input type="radio" name="RESTAURERAVECRESTOREWITH" value="Boulette de cotton et restauration temporaire / Cotton pellet & temporary restoration" checked="checked"><span class="wpcf7-list-item-label">Boulette de cotton et restauration temporaire / Cotton pellet & temporary restoration</span></span><span class="wpcf7-list-item last"><input type="radio" name="RESTAURERAVECRESTOREWITH" value="Restauration finale en composite / Final composite"><span class="wpcf7-list-item-label">Restauration finale en composite / Final composite</span></span></span></span>
  86. </div>
  87. <p class="font-18 text-uppercase">Espace pivot / <i>Post space</i></p>
  88. <div class="form-group">
  89. <span class="wpcf7-form-control-wrap ESPACEPIVOTPOSTSPACE"><span class="wpcf7-form-control wpcf7-radio w3-radio"><span class="wpcf7-list-item first"><input type="radio" name="ESPACEPIVOTPOSTSPACE" value="Oui / Yes" checked="checked"><span class="wpcf7-list-item-label">Oui / Yes</span></span><span class="wpcf7-list-item last"><input type="radio" name="ESPACEPIVOTPOSTSPACE" value="Non / No"><span class="wpcf7-list-item-label">Non / No</span></span></span></span>
  90. </div>
  91. </div>
  92. <div class="form-group col-md-12">
  93. <hr>
  94. </div>
  95. <div class="col-md-6">
  96. <p class="font-18 text-uppercase">Radiographie(s) / <i>Radiograph(s)</i></p>
  97. <div class="form-group">
  98. <span class="wpcf7-form-control-wrap RADIOGRAPHIESRADIOGRAPHS"><span class="wpcf7-form-control wpcf7-radio w3-radio fullo"><span class="wpcf7-list-item first"><input type="radio" name="RADIOGRAPHIESRADIOGRAPHS" value="Par la poste / By mail" checked="checked"><span class="wpcf7-list-item-label">Par la poste / By mail</span></span><span class="wpcf7-list-item last"><input type="radio" name="RADIOGRAPHIESRADIOGRAPHS" value="Par courriel / By email"><span class="wpcf7-list-item-label">Par courriel / By email</span></span></span></span>
  99. </div>
  100. <div class="form-group">
  101. <label>Joindre vos radios / Attach you Xrays (.pdf .jpg)<br>( plusieurs fichiers autorisés / multiple files allowed)</label><br>
  102. <span class="wpcf7-form-control-wrap attachments"><input type="file" name="attachments[]" size="40" class="wpcf7-form-control wpcf7-multifile w3-input w3-border" multiple="multiple" aria-invalid="false"></span>
  103. </div>
  104. </div>
  105. <div class="col-md-6">
  106. <p class="font-18 text-uppercase">Envoyer le rapport / <i>Send report</i></p>
  107. <div class="form-group">
  108. <span class="wpcf7-form-control-wrap ENVOYERLERAPPORTSENDREPORT"><span class="wpcf7-form-control wpcf7-radio w3-radio fullo"><span class="wpcf7-list-item first"><input type="radio" name="ENVOYERLERAPPORTSENDREPORT" value="Par la poste / By mail" checked="checked"><span class="wpcf7-list-item-label">Par la poste / By mail</span></span><span class="wpcf7-list-item last"><input type="radio" name="ENVOYERLERAPPORTSENDREPORT" value="Par courriel / By email"><span class="wpcf7-list-item-label">Par courriel / By email</span></span></span></span>
  109. </div>
  110. </div>
  111. <div class="form-group col-md-12">
  112. <hr>
  113. </div>
  114. <div class="form-group col-md-12">
  115. <label class="text-uppercase">Remarques / <i>Comments</i></label><br>
  116. <span class="wpcf7-form-control-wrap REMARQUESCOMMENTS"><textarea name="REMARQUESCOMMENTS" cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea w3-text w3-border" aria-invalid="false"></textarea></span>
  117. </div>
  118. <div class="form-group col-md-12 text-right">
  119. <input type="submit" class="btn" value="soumettre">
  120. </div>
  121. </div>
  122. <div class="wpcf7-response-output wpcf7-display-none"></div></form>
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