{"id":1156,"date":"2023-04-01T13:13:01","date_gmt":"2023-04-01T13:13:01","guid":{"rendered":"https:\/\/malikabaci.com\/?page_id=1156"},"modified":"2024-11-26T17:40:25","modified_gmt":"2024-11-26T17:40:25","slug":"online-consultation","status":"publish","type":"page","link":"https:\/\/malikabaci.com\/fr\/online-consultation\/","title":{"rendered":"Consultation en ligne"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"1156\" class=\"elementor elementor-1156\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3de72d99 elementor-section-full_width elementor-section-height-min-height animated-slow elementor-section-height-default elementor-section-items-middle elementor-invisible\" data-id=\"3de72d99\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;fadeIn&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5fe52fef\" data-id=\"5fe52fef\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-315627aa elementor-absolute elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"315627aa\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;absolute&quot;,&quot;_animation&quot;:&quot;fadeInDown&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-large\">obtenir un devis<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-acc578a elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"acc578a\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-04239e9\" data-id=\"04239e9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0013848 elementor-widget elementor-widget-shortcode\" data-id=\"0013848\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-4747 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-4747\" data-uid=\"6a23d3df6f82e\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-4747\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-4747 forminator-design--material  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"4747\"\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"default\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a23d3df6f82e\" action=\"\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-4747--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-4747--page-0-label\"\n\t\t\t\tdata-step=\"0\"\n\t\t\t\tdata-label=\"Termin\u00e9\"\n\t\t\t\tdata-actual-label=\"Page 1\"\n\t\t\t\tdata-name=\"page-break-1\"\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Renseignements personnels<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid #1597d3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a23d3df6f82e\" id=\"forminator-field-name-1_6a23d3df6f82e-label\" class=\"forminator-label\">Nom - Nom de famille <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-1_6a23d3df6f82e-description\" \/><span id=\"forminator-field-name-1_6a23d3df6f82e-description\" class=\"forminator-description\">Le nom complet est obligatoire.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a23d3df6f82e\" id=\"forminator-field-date-1-picker_6a23d3df6f82e-label\" class=\"forminator-label\">Date de naissance <span class=\"forminator-required\">*<\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choisir une date\" id=\"forminator-field-date-1-picker_6a23d3df6f82e\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2006\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"08\/01\/2006\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" aria-describedby=\"forminator-field-date-1-picker_6a23d3df6f82e-description\" \/><span id=\"forminator-field-date-1-picker_6a23d3df6f82e-description\" class=\"forminator-description\">Vous devez avoir 18 ans ou plus<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-18\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-18-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-18-6a23d3df6f82e-label\" class=\"forminator-label\">Quel est votre genre ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-18-label-1\" for=\"forminator-field-radio-18-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"M\u00e2le\"><input type=\"radio\" name=\"radio-18\" value=\"one\" id=\"forminator-field-radio-18-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-18-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">M\u00e2le<\/span><\/label><label id=\"forminator-field-radio-18-label-2\" for=\"forminator-field-radio-18-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Femelle\"><input type=\"radio\" name=\"radio-18\" value=\"two\" id=\"forminator-field-radio-18-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-18-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Femelle<\/span><\/label><label id=\"forminator-field-radio-18-label-3\" for=\"forminator-field-radio-18-3-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Ind\u00e9termin\u00e9\"><input type=\"radio\" name=\"radio-18\" value=\"Unspecified\" id=\"forminator-field-radio-18-3-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-18-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Ind\u00e9termin\u00e9<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a23d3df6f82e\" id=\"forminator-field-email-1_6a23d3df6f82e-label\" class=\"forminator-label\">Adresse e-mail <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"Par exemple, john@doe.com\" id=\"forminator-field-email-1_6a23d3df6f82e\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a23d3df6f82e\" id=\"forminator-field-phone-1_6a23d3df6f82e-label\" class=\"forminator-label\">Num\u00e9ro de portable <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"Par exemple +1 300 400 5000\" id=\"forminator-field-phone-1_6a23d3df6f82e\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" aria-describedby=\"forminator-field-phone-1_6a23d3df6f82e-description\" \/><span id=\"forminator-field-phone-1_6a23d3df6f82e-description\" class=\"forminator-description\">Notre \u00e9quipe vous contactera via WhatsApp. Veuillez fournir votre num\u00e9ro WhatsApp actif avec l&#039;indicatif du pays. Si vous n&#039;utilisez pas WhatsApp, veuillez s\u00e9lectionner votre m\u00e9thode de communication pr\u00e9f\u00e9r\u00e9e parmi les options ci-dessous.<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-6a23d3df6f82e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6a23d3df6f82e-label\" class=\"forminator-label\">M\u00e9thode de communication pr\u00e9f\u00e9r\u00e9e autre que WhatsApp<\/span><label id=\"forminator-field-checkbox-3-1-6a23d3df6f82e-label\" for=\"forminator-field-checkbox-3-1-6a23d3df6f82e\" class=\"forminator-checkbox\" title=\"E-mail\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Email\" id=\"forminator-field-checkbox-3-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-checkbox-3-1-6a23d3df6f82e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">E-mail<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6a23d3df6f82e-label\" for=\"forminator-field-checkbox-3-2-6a23d3df6f82e\" class=\"forminator-checkbox\" title=\"Par appel\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-checkbox-3-2-6a23d3df6f82e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Par appel<\/span><\/label><label id=\"forminator-field-checkbox-3-3-6a23d3df6f82e-label\" for=\"forminator-field-checkbox-3-3-6a23d3df6f82e\" class=\"forminator-checkbox\" title=\"Autre (t\u00e9l\u00e9gramme, signal, etc.)\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Other-(Telegram,-Signal-etc.)\" id=\"forminator-field-checkbox-3-3-6a23d3df6f82e\" aria-labelledby=\"forminator-field-checkbox-3-3-6a23d3df6f82e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Autre (t\u00e9l\u00e9gramme, signal, etc.)<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_6a23d3df6f82e\" id=\"forminator-field-text-11_6a23d3df6f82e-label\" class=\"forminator-label\">If you&#039;ve selected &#039;Other&#039; in the previous question, please specify your <strong>*preferred*<\/strong> communication method.<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"Autre (t\u00e9l\u00e9gramme, signal, etc.)\" id=\"forminator-field-text-11_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-country\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-4747__field--address-1-country_6a23d3df6f82e\" id=\"forminator-field-4747__field--address-1-country_6a23d3df6f82e-label\" class=\"forminator-label\">Pays <span class=\"forminator-required\">*<\/span><\/label><select name=\"address-1-country\" id=\"forminator-field-4747__field--address-1-country_6a23d3df6f82e\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"S\u00e9lectionner un pays\" autocomplete=\"country-name country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Afrique du Sud\" data-country-code=\"ZA\" >Afrique du Sud<\/option><option value=\"Albanie\" data-country-code=\"AL\" >Albanie<\/option><option value=\"Alg\u00e9rie\" data-country-code=\"DZ\" >Alg\u00e9rie<\/option><option value=\"Allemagne\" data-country-code=\"DE\" >Allemagne<\/option><option value=\"Andorre\" data-country-code=\"AD\" >Andorre<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctique\" data-country-code=\"AQ\" >Antarctique<\/option><option value=\"Antigua-et-Barbuda\" data-country-code=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"Antilles N\u00e9erlandaises\" data-country-code=\"AN\" >Antilles N\u00e9erlandaises<\/option><option value=\"Apatrides\" data-country-code=\"XX\" >Apatrides<\/option><option value=\"Arabie Saoudite\" data-country-code=\"SA\" >Arabie Saoudite<\/option><option value=\"Argentine\" data-country-code=\"AR\" >argentin<\/option><option value=\"Arm\u00e9nie\" data-country-code=\"AM\" >Arm\u00e9nie<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australie\" data-country-code=\"AU\" >Australie<\/option><option value=\"Autriche\" data-country-code=\"AT\" >Autriche<\/option><option value=\"Azerba\u00efdjan\" data-country-code=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahre\u00efn\" data-country-code=\"BH\" >Bahre\u00efn<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Belgique\" data-country-code=\"BE\" >Belgique<\/option><option value=\"Bermudes\" data-country-code=\"BM\" >Bermudes<\/option><option value=\"Bhoutan\" data-country-code=\"BT\" >Bhoutan<\/option><option value=\"Bi\u00e9lorussie\" data-country-code=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"Bolivie\" data-country-code=\"BO\" >Bolivie<\/option><option value=\"Bosnie-Herz\u00e9govine\" data-country-code=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brun\u00e9i<\/option><option value=\"Br\u00e9sil\" data-country-code=\"BR\" >Br\u00e9sil<\/option><option value=\"Bulgarie\" data-country-code=\"BG\" >Bulgarie<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"B\u00e9lize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"B\u00e9nin\" data-country-code=\"BJ\" >B\u00e9nin<\/option><option value=\"Cambodge\" data-country-code=\"KH\" >Cambodge<\/option><option value=\"Cameroun\" data-country-code=\"CM\" >Cameroun<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cap Vert\" data-country-code=\"CV\" >Cap-Vert<\/option><option value=\"Chili\" data-country-code=\"CL\" >le Chili<\/option><option value=\"Chine, R\u00e9publique populaire de\" data-country-code=\"CN\" >Chine, R\u00e9publique populaire de<\/option><option value=\"Chypre\" data-country-code=\"CY\" >Chypr\u00e9<\/option><option value=\"Cit\u00e9 du Vatican\" data-country-code=\"VA\" >Cit\u00e9 du Vatican<\/option><option value=\"Colombie\" data-country-code=\"CO\" >Colombie<\/option><option value=\"Comores\" data-country-code=\"KM\" >Comores<\/option><option value=\"Congo, R\u00e9publique du\" data-country-code=\"CG\" >Congo, R\u00e9publique du<\/option><option value=\"Congo, R\u00e9publique d\u00e9mocratique du\" data-country-code=\"CD\" >Congo, R\u00e9publique d\u00e9mocratique du<\/option><option value=\"Cor\u00e9e, R\u00e9publique de\" data-country-code=\"KR\" >Cor\u00e9e, R\u00e9publique de<\/option><option value=\"Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de\" data-country-code=\"KP\" >Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatie\" data-country-code=\"HR\" >Croatie<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Curacao<\/option><option value=\"C\u00f4te d\u2019Ivoire\" data-country-code=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"Danemark\" data-country-code=\"DK\" >Danemark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominique\" data-country-code=\"DM\" >Dominique<\/option><option value=\"Espagne\" data-country-code=\"ES\" >Espagne<\/option><option value=\"Estonie\" data-country-code=\"EE\" >Estonie<\/option><option value=\"Fidji\" data-country-code=\"FJ\" >Fidji<\/option><option value=\"Finlande\" data-country-code=\"FI\" >Finlande<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, M\u00e9tropolitaine\" data-country-code=\"FX\" >France M\u00e9tropolitaine<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambie\" data-country-code=\"GM\" >Gambie<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Grenade\" data-country-code=\"GD\" >Grenade<\/option><option value=\"Groenland\" data-country-code=\"GL\" >Groenland<\/option><option value=\"Gr\u00e8ce\" data-country-code=\"GR\" >Gr\u00e8ce<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guat\u00e9mala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernesey\" data-country-code=\"GG\" >Guernesey<\/option><option value=\"Guin\u00e9e\" data-country-code=\"GN\" >Guin\u00e9e<\/option><option value=\"Guin\u00e9e \u00c9quatoriale\" data-country-code=\"GQ\" >Guin\u00e9e \u00c9quatoriale<\/option><option value=\"Guin\u00e9e-Bissau\" data-country-code=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\" data-country-code=\"GY\" >Guyane<\/option><option value=\"Guyane fran\u00e7aise\" data-country-code=\"GF\" >Guyane fran\u00e7aise<\/option><option value=\"G\u00e9orgie\" data-country-code=\"GE\" >G\u00e9orgie<\/option><option value=\"G\u00e9orgie du Sud et Sandwich du Sud\" data-country-code=\"GS\" >G\u00e9orgie du Sud et Sandwich du Sud<\/option><option value=\"Ha\u00efti\" data-country-code=\"HT\" >Ha\u00efti<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hongrie\" data-country-code=\"HU\" >Hongrie<\/option><option value=\"Inde\" data-country-code=\"IN\" >Inde<\/option><option value=\"Indon\u00e9sie\" data-country-code=\"ID\" >Indon\u00e9sie<\/option><option value=\"Iran\" data-country-code=\"IR\" >L&#039;Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Irak<\/option><option value=\"Irlande\" data-country-code=\"IE\" >Irlande<\/option><option value=\"Islande\" data-country-code=\"IS\" >\u00cele<\/option><option value=\"Israel\" data-country-code=\"IL\" >Isra\u00ebl<\/option><option value=\"Italie\" data-country-code=\"IT\" >Italie<\/option><option value=\"Jama\u00efque\" data-country-code=\"JM\" >Jama\u00efque<\/option><option value=\"Japon\" data-country-code=\"JP\" >Japon<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Jordanie\" data-country-code=\"JO\" >Jordanie<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kirghizistan\" data-country-code=\"KG\" >Kirghizistan<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kowe\u00eft\" data-country-code=\"KW\" >Kowe\u00eft<\/option><option value=\"La Barbade\" data-country-code=\"BB\" >La Barbade<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Lettonie\" data-country-code=\"LV\" >Lettonie<\/option><option value=\"Liban\" data-country-code=\"LB\" >Liban<\/option><option value=\"Libye\" data-country-code=\"LY\" >Libye<\/option><option value=\"Lib\u00e9ria\" data-country-code=\"LR\" >Lib\u00e9ria<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuanie\" data-country-code=\"LT\" >Lituanie<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao\" data-country-code=\"MO\" >Macao<\/option><option value=\"Mac\u00e9doine du Nord\" data-country-code=\"MK\" >Mac\u00e9doine du Nord<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malaisie\" data-country-code=\"MY\" >Malaisie<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malte\" data-country-code=\"MT\" >Malte<\/option><option value=\"Maroc\" data-country-code=\"MA\" >Maroc<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritanie\" data-country-code=\"MR\" >Mauritanie<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexique\" data-country-code=\"MX\" >Mexique<\/option><option value=\"Micron\u00e9sie\" data-country-code=\"FM\" >Micron\u00e9sie<\/option><option value=\"Moldavie\" data-country-code=\"MD\" >Moldavie<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolie\" data-country-code=\"MN\" >Mongolie<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Mont\u00e9n\u00e9gro\" data-country-code=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Birmanie<\/option><option value=\"Namibie\" data-country-code=\"NA\" >Namibie<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niu\u00e9\" data-country-code=\"NU\" >Niu\u00e9<\/option><option value=\"Norv\u00e8ge\" data-country-code=\"NO\" >Norv\u00e8ge<\/option><option value=\"Nouvelle Zelande\" data-country-code=\"NZ\" >Nouvelle-Z\u00e9lande<\/option><option value=\"Nouvelle-Cal\u00e9donie\" data-country-code=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"N\u00e9pal\" data-country-code=\"NP\" >N\u00e9pal<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Ouganda\" data-country-code=\"UG\" >Ouganda<\/option><option value=\"Ouzb\u00e9kistan\" data-country-code=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palaos<\/option><option value=\"Palestine, \u00c9tat de\" data-country-code=\"PS\" >Palestine, \u00c9tat de<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\" data-country-code=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Pays-Bas\" data-country-code=\"NL\" >Pays Bas<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pologne\" data-country-code=\"PL\" >Pologne<\/option><option value=\"Polyn\u00e9sie Fran\u00e7aise\" data-country-code=\"PF\" >Polyn\u00e9sie Fran\u00e7aise<\/option><option value=\"Porto Rico\" data-country-code=\"PR\" >Porto Rico<\/option><option value=\"Portugal\" data-country-code=\"PT\" >le Portugal<\/option><option value=\"P\u00e9rou\" data-country-code=\"PE\" >P\u00e9rou<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Roumanie\" data-country-code=\"RO\" >Roumanie<\/option><option value=\"Royaume-Uni\" data-country-code=\"GB\" >Royaume-Uni<\/option><option value=\"Russie\" data-country-code=\"RU\" >Russie<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"R\u00e9publique Centrafricaine\" data-country-code=\"CF\" >R\u00e9publique Centrafricaine<\/option><option value=\"R\u00e9publique Dominicaine\" data-country-code=\"DO\" >R\u00e9publique Dominicaine<\/option><option value=\"R\u00e9publique Tch\u00e8que\" data-country-code=\"CZ\" >R\u00e9publique Tch\u00e8que<\/option><option value=\"R\u00e9publique du Salvador\" data-country-code=\"SV\" >R\u00e9publique du Salvador<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire du Laos\" data-country-code=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"Sahara occidental\" data-country-code=\"EH\" >Sahara occidental<\/option><option value=\"Saint Pierre et Miquelon\" data-country-code=\"PM\" >Saint-Pierre-et-Miquelon<\/option><option value=\"Saint-Kitts-et-Nevis\" data-country-code=\"KN\" >Saint-Kitts-et-Nevis<\/option><option value=\"Saint-Marin\" data-country-code=\"SM\" >Saint Marin<\/option><option value=\"Saint-Martin (Royaume des Pays-Bas)\" data-country-code=\"MF\" >Saint-Martin (Royaume des Pays-Bas)<\/option><option value=\"Saint-Vincent-et-les-Grenadines\" data-country-code=\"VC\" >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Sainte Lucie\" data-country-code=\"LC\" >Sainte-Lucie<\/option><option value=\"Sainte-H\u00e9l\u00e8ne\" data-country-code=\"SH\" >Sainte-H\u00e9l\u00e8ne<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Samoa am\u00e9ricaines\" data-country-code=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"Sao Tom\u00e9-et-Principe\" data-country-code=\"ST\" >Sao Tom\u00e9-et-Principe<\/option><option value=\"Serbie\" data-country-code=\"RS\" >Serbie<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >les Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapour\" data-country-code=\"SG\" >Singapour<\/option><option value=\"Slovaquie\" data-country-code=\"SK\" >Slovaquie<\/option><option value=\"Slov\u00e9nie\" data-country-code=\"SI\" >Slov\u00e9nie<\/option><option value=\"Somalie\" data-country-code=\"SO\" >Somalie<\/option><option value=\"Soudan\" data-country-code=\"SD\" >Soudan<\/option><option value=\"Soudan, Sud\" data-country-code=\"SS\" >Soudan, Sud<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Suisse\" data-country-code=\"CH\" >Suisse<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Surinam<\/option><option value=\"Su\u00e8de\" data-country-code=\"SE\" >Su\u00e8de<\/option><option value=\"Svalbard et Jan Mayen\" data-country-code=\"SJ\" >Svalbard et Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Syrie\" data-country-code=\"SY\" >Syrie<\/option><option value=\"S\u00e9n\u00e9gal\" data-country-code=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"Tadjikistan\" data-country-code=\"TJ\" >Tadjikistan<\/option><option value=\"Taiwan, R\u00e9publique de Chine\" data-country-code=\"TW\" >Ta\u00efwan, R\u00e9publique de Chine<\/option><option value=\"Tanzanie\" data-country-code=\"TZ\" >Tanzanie<\/option><option value=\"Tchad\" data-country-code=\"TD\" >Tchad<\/option><option value=\"Terres australes et antarctiques fran\u00e7aises\" data-country-code=\"TF\" >Terres australes et antarctiques fran\u00e7aises<\/option><option value=\"Territoire britannique de l\u2019oc\u00e9an Indien\" data-country-code=\"IO\" >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value=\"Tha\u00eflande\" data-country-code=\"TH\" >Tha\u00eflande<\/option><option value=\"Timor-Oriental\" data-country-code=\"TL\" >Timor-Oriental<\/option><option value=\"Togo\" data-country-code=\"TG\" >Aller<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tok\u00e9laou<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinit\u00e9 et Tobago\" data-country-code=\"TT\" >Trinit\u00e9 et Tobago<\/option><option value=\"Tunisie\" data-country-code=\"TN\" >Tunisie<\/option><option value=\"Turkm\u00e9nistan\" data-country-code=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"Turquie\" data-country-code=\"TR\" >Turquie<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vi\u00eat Nam<\/option><option value=\"V\u00e9n\u00e9zu\u00e9la\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Y\u00e9men<\/option><option value=\"Zambie\" data-country-code=\"ZM\" >Zambie<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><option value=\"\u00c9gypte\" data-country-code=\"EG\" >Egypt<\/option><option value=\"\u00c9mirats Arabes Unis\" data-country-code=\"AE\" >\u00c9mirats Arabes Unis<\/option><option value=\"\u00c9quateur\" data-country-code=\"EC\" >\u00c9quateur<\/option><option value=\"\u00c9rythr\u00e9e\" data-country-code=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"\u00c9tats-Unis d\u2019Am\u00e9rique (USA)\" data-country-code=\"US\" >\u00c9tats-Unis d&#039;Am\u00e9rique (USA)<\/option><option value=\"\u00c9thiopie\" data-country-code=\"ET\" >\u00c9thiopie<\/option><option value=\"\u00cele Bouvet\" data-country-code=\"BV\" >\u00cele Bouvet<\/option><option value=\"\u00cele Christmas\" data-country-code=\"CX\" >\u00cele No\u00ebl<\/option><option value=\"\u00cele Heard et \u00eele Mcdonald\" data-country-code=\"HM\" >\u00cele Heard et \u00eele Mcdonald<\/option><option value=\"\u00cele Johnston\" data-country-code=\"JT\" >\u00cele Johnston<\/option><option value=\"\u00cele Maurice\" data-country-code=\"MU\" >\u00cele-Maurice<\/option><option value=\"\u00cele Norfolk\" data-country-code=\"NF\" >\u00cele Norfolk<\/option><option value=\"\u00cele de la R\u00e9union\" data-country-code=\"RE\" >\u00cele de la R\u00e9union<\/option><option value=\"\u00celes Ca\u00efmans\" data-country-code=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"\u00celes Cocos\" data-country-code=\"CC\" >\u00celes Cocos<\/option><option value=\"\u00celes Cook\" data-country-code=\"CK\" >\u00celes Cook<\/option><option value=\"\u00celes Falkland\" data-country-code=\"FK\" >\u00celes Falkland<\/option><option value=\"\u00celes F\u00e9ro\u00e9\" data-country-code=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Mariannes du Nord\" data-country-code=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"\u00celes Marshall\" data-country-code=\"MH\" >\u00celes Marshall<\/option><option value=\"\u00celes Pitcairn\" data-country-code=\"PN\" >\u00celes Pitcairn<\/option><option value=\"\u00celes Salomon\" data-country-code=\"SB\" >\u00celes Salomon<\/option><option value=\"\u00celes Turques-et-Ca\u00efques\" data-country-code=\"TC\" >\u00celes Turques-et-Ca\u00efques<\/option><option value=\"\u00celes Vierges am\u00e9ricaines\" data-country-code=\"VI\" >\u00celes Vierges am\u00e9ricaines<\/option><option value=\"\u00celes Vierges britanniques\" data-country-code=\"VG\" >\u00celes Vierges britanniques<\/option><option value=\"\u00celes Wallis et Futuna\" data-country-code=\"WF\" >\u00celes Wallis et Futuna<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\" data-country-code=\"UM\" >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_6a23d3df6f82e\" id=\"forminator-field-text-8_6a23d3df6f82e-label\" class=\"forminator-label\">Profession<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"Intitul\u00e9 ou statut actuel du poste\" id=\"forminator-field-text-8_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-28\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-28-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-28-6a23d3df6f82e-label\" class=\"forminator-label\">\u00c9tat matrimonial<\/span><label id=\"forminator-field-radio-28-label-1\" for=\"forminator-field-radio-28-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"C\u00e9libataire\"><input type=\"radio\" name=\"radio-28\" value=\"one\" id=\"forminator-field-radio-28-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-28-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">C\u00e9libataire<\/span><\/label><label id=\"forminator-field-radio-28-label-2\" for=\"forminator-field-radio-28-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Mari\u00e9\"><input type=\"radio\" name=\"radio-28\" value=\"two\" id=\"forminator-field-radio-28-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-28-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Mari\u00e9<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_6a23d3df6f82e\" id=\"forminator-field-number-1_6a23d3df6f82e-label\" class=\"forminator-label\">Poids (en kilogrammes) <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_6a23d3df6f82e\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_6a23d3df6f82e\" id=\"forminator-field-number-2_6a23d3df6f82e-label\" class=\"forminator-label\">Hauteur (en centim\u00e8tres) <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-2\" value=\"\" placeholder=\"\" id=\"forminator-field-number-2_6a23d3df6f82e\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"1500\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"calculation-1\" class=\"forminator-field-calculation forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"calculation-1-field_6a23d3df6f82e\" id=\"calculation-1-field_6a23d3df6f82e-label\" class=\"forminator-label\">Calculated BMI<\/label><input type=\"text\" name=\"calculation-1\" value=\"\" id=\"calculation-1-field_6a23d3df6f82e\" class=\"forminator-calculation forminator-input\" data-formula=\"{number-1} \/ (({number-2} \/ 100) * ({number-2} \/ 100))\" data-required=\"\" data-decimal-point=\".\" data-precision=\"2\" data-is-hidden=\"\" disabled=\"disabled\" data-decimals=\"2\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" readonly=\"readonly\" data-hidden-behavior=\"zero\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12\"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><div style=\"background-color: #ffe6e6;color: red;border: 2px solid red;padding: 10px;border-radius: 5px;font-weight: bold;font-size: 1.1em\">\u26a0 A higher BMI can present additional considerations for surgery. Your surgeon will review your medical profile to ensure the safest approach for your goals<\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a23d3df6f82e\" id=\"forminator-field-text-6_6a23d3df6f82e-label\" class=\"forminator-label\">Veuillez saisir quelle op\u00e9ration vous int\u00e9resse <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"Abdominoplastie, BBL, liposuccion, etc.\" id=\"forminator-field-text-6_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-26\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-26-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-26-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous un enfant ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-26-label-1\" for=\"forminator-field-radio-26-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-26\" value=\"one\" id=\"forminator-field-radio-26-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-26-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-26-label-2\" for=\"forminator-field-radio-26-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-26\" value=\"two\" id=\"forminator-field-radio-26-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-26-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-27\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-27-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-27-6a23d3df6f82e-label\" class=\"forminator-label\">\u00cates-vous enceinte ou envisagez-vous de devenir enceinte ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-27-label-1\" for=\"forminator-field-radio-27-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-27\" value=\"one\" id=\"forminator-field-radio-27-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-27-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-27-label-2\" for=\"forminator-field-radio-27-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-27\" value=\"two\" id=\"forminator-field-radio-27-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-27-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a23d3df6f82e\" id=\"forminator-field-text-2_6a23d3df6f82e-label\" class=\"forminator-label\">Temps \u00e9coul\u00e9 depuis le dernier accouchement ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte\" id=\"forminator-field-text-2_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a23d3df6f82e\" id=\"forminator-field-text-3_6a23d3df6f82e-label\" class=\"forminator-label\">Temps \u00e9coul\u00e9 depuis le dernier allaitement\u00a0? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte\" id=\"forminator-field-text-3_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-4747--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-4747--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"Page 1\"\n\t\t\t\tdata-actual-label=\"Page 2\"\n\t\t\t\tdata-name=\"page-break-3\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Ant\u00e9c\u00e9dents m\u00e9dicaux<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-17\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-17-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-17-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous un probl\u00e8me de sant\u00e9\u00a0? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-17-label-1\" for=\"forminator-field-radio-17-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-17\" value=\"one\" id=\"forminator-field-radio-17-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-17-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-17-label-2\" for=\"forminator-field-radio-17-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-17\" value=\"two\" id=\"forminator-field-radio-17-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-17-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6a23d3df6f82e\" id=\"forminator-field-textarea-6_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez s\u00e9lectionn\u00e9 \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer :<\/label><textarea name=\"textarea-6\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-6_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-5-6a23d3df6f82e-label\" class=\"forminator-label\">Diab\u00e8te <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-6-6a23d3df6f82e-label\" class=\"forminator-label\">Maladie thyro\u00efdienne <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-7-6a23d3df6f82e-label\" class=\"forminator-label\">Arthrite <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-8-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-8-6a23d3df6f82e-label\" class=\"forminator-label\">Maladie du rein <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-8\" value=\"one\" id=\"forminator-field-radio-8-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-8\" value=\"two\" id=\"forminator-field-radio-8-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-22\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-22-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-22-6a23d3df6f82e-label\" class=\"forminator-label\">Maladie cardiaque <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-22-label-1\" for=\"forminator-field-radio-22-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-22\" value=\"one\" id=\"forminator-field-radio-22-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-22-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-22-label-2\" for=\"forminator-field-radio-22-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-22\" value=\"two\" id=\"forminator-field-radio-22-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-22-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-19\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-19-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-19-6a23d3df6f82e-label\" class=\"forminator-label\">Asthme <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-19-label-1\" for=\"forminator-field-radio-19-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-19\" value=\"one\" id=\"forminator-field-radio-19-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-19-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-19-label-2\" for=\"forminator-field-radio-19-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-19\" value=\"two\" id=\"forminator-field-radio-19-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-19-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-20\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-20-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-20-6a23d3df6f82e-label\" class=\"forminator-label\">Maladie pulmonaire <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-20-label-1\" for=\"forminator-field-radio-20-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-20\" value=\"one\" id=\"forminator-field-radio-20-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-20-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-20-label-2\" for=\"forminator-field-radio-20-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-20\" value=\"two\" id=\"forminator-field-radio-20-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-20-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-21\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-21-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-21-6a23d3df6f82e-label\" class=\"forminator-label\">Hypertension (pression art\u00e9rielle \u00e9lev\u00e9e) <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-21-label-1\" for=\"forminator-field-radio-21-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-21\" value=\"one\" id=\"forminator-field-radio-21-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-21-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-21-label-2\" for=\"forminator-field-radio-21-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-21\" value=\"two\" id=\"forminator-field-radio-21-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-21-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-9-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-9-6a23d3df6f82e-label\" class=\"forminator-label\">Accident vasculaire c\u00e9r\u00e9bral <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-9\" value=\"one\" id=\"forminator-field-radio-9-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-9\" value=\"two\" id=\"forminator-field-radio-9-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-10-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-10-6a23d3df6f82e-label\" class=\"forminator-label\">VIH <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-10\" value=\"one\" id=\"forminator-field-radio-10-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-10\" value=\"two\" id=\"forminator-field-radio-10-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-11\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-11-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-11-6a23d3df6f82e-label\" class=\"forminator-label\">H\u00e9patite <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-11-label-1\" for=\"forminator-field-radio-11-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-11\" value=\"one\" id=\"forminator-field-radio-11-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-11-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-11-label-2\" for=\"forminator-field-radio-11-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-11\" value=\"two\" id=\"forminator-field-radio-11-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-11-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-12\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-12-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-12-6a23d3df6f82e-label\" class=\"forminator-label\">Fumez-vous? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-12-label-1\" for=\"forminator-field-radio-12-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-12\" value=\"one\" id=\"forminator-field-radio-12-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-12-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-12-label-2\" for=\"forminator-field-radio-12-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-12\" value=\"two\" id=\"forminator-field-radio-12-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-12-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-13\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-13-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-13-6a23d3df6f82e-label\" class=\"forminator-label\">Ulc\u00e8res d&#039;estomac <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-13-label-1\" for=\"forminator-field-radio-13-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-13\" value=\"one\" id=\"forminator-field-radio-13-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-13-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-13-label-2\" for=\"forminator-field-radio-13-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-13\" value=\"two\" id=\"forminator-field-radio-13-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-13-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-14\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-14-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-14-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous une dr\u00e9panocytose ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-14-label-1\" for=\"forminator-field-radio-14-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-14\" value=\"one\" id=\"forminator-field-radio-14-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-14-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-14-label-2\" for=\"forminator-field-radio-14-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-14\" value=\"two\" id=\"forminator-field-radio-14-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-14-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-16\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-16-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-16-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous subi des proc\u00e9dures\/chirurgies de perte de poids\u00a0? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-16-label-1\" for=\"forminator-field-radio-16-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-16\" value=\"one\" id=\"forminator-field-radio-16-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-16-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-16-label-2\" for=\"forminator-field-radio-16-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-16\" value=\"two\" id=\"forminator-field-radio-16-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-16-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-15\" class=\"forminator-field-radio forminator-col forminator-col-3\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-15-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-15-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous de l&#039;an\u00e9mie ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-15-label-1\" for=\"forminator-field-radio-15-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-15\" value=\"one\" id=\"forminator-field-radio-15-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-15-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-15-label-2\" for=\"forminator-field-radio-15-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-15\" value=\"two\" id=\"forminator-field-radio-15-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-15-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-23\" class=\"forminator-field-radio forminator-col forminator-col-4\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-23-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-23-6a23d3df6f82e-label\" class=\"forminator-label\">Troubles de la coagulation <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-23-label-1\" for=\"forminator-field-radio-23-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-23\" value=\"one\" id=\"forminator-field-radio-23-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-23-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-23-label-2\" for=\"forminator-field-radio-23-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-23\" value=\"two\" id=\"forminator-field-radio-23-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-23-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-24\" class=\"forminator-field-radio forminator-col forminator-col-4\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-24-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-24-6a23d3df6f82e-label\" class=\"forminator-label\">Maladies auto-immunes <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-24-label-1\" for=\"forminator-field-radio-24-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-24\" value=\"one\" id=\"forminator-field-radio-24-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-24-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-24-label-2\" for=\"forminator-field-radio-24-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-24\" value=\"two\" id=\"forminator-field-radio-24-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-24-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-25\" class=\"forminator-field-radio forminator-col forminator-col-4\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-25-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-25-6a23d3df6f82e-label\" class=\"forminator-label\">Utilisation de suppl\u00e9ments \u00e0 base de plantes ou de vitamines <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-25-label-1\" for=\"forminator-field-radio-25-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-25\" value=\"one\" id=\"forminator-field-radio-25-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-25-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-25-label-2\" for=\"forminator-field-radio-25-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-25\" value=\"two\" id=\"forminator-field-radio-25-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-25-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-4-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous des maladies chroniques? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6a23d3df6f82e\" id=\"forminator-field-textarea-4_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer<\/label><textarea name=\"textarea-4\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-4_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-1-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous d\u00e9j\u00e0 subi des op\u00e9rations chirurgicales\u00a0? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a23d3df6f82e\" id=\"forminator-field-textarea-1_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab\u00a0Oui\u00a0\u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer et inclure la date de l&#039;intervention chirurgicale.<\/label><textarea name=\"textarea-1\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-1_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-29\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-29-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-29-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous subi des proc\u00e9dures\/chirurgies de perte de poids\u00a0? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-29-label-1\" for=\"forminator-field-radio-29-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-29\" value=\"one\" id=\"forminator-field-radio-29-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-29-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-29-label-2\" for=\"forminator-field-radio-29-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-29\" value=\"two\" id=\"forminator-field-radio-29-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-29-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-8\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-8_6a23d3df6f82e\" id=\"forminator-field-textarea-8_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab\u00a0Oui\u00a0\u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer et inclure la date de l&#039;intervention chirurgicale.<\/label><textarea name=\"textarea-8\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-8_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-2-6a23d3df6f82e-label\" class=\"forminator-label\">Utilisez-vous actuellement des m\u00e9dicaments ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a23d3df6f82e\" id=\"forminator-field-textarea-2_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer<\/label><textarea name=\"textarea-2\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-2_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-3-6a23d3df6f82e-label\" class=\"forminator-label\">As tu des allergies? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a23d3df6f82e\" id=\"forminator-field-textarea-3_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer<\/label><textarea name=\"textarea-3\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-3_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-31\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-31-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-31-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous une dr\u00e9panocytose ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-31-label-1\" for=\"forminator-field-radio-31-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-31\" value=\"one\" id=\"forminator-field-radio-31-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-31-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-31-label-2\" for=\"forminator-field-radio-31-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-31\" value=\"two\" id=\"forminator-field-radio-31-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-31-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-30\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-30-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-30-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous de l&#039;an\u00e9mie ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-30-label-1\" for=\"forminator-field-radio-30-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-30\" value=\"one\" id=\"forminator-field-radio-30-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-30-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-30-label-2\" for=\"forminator-field-radio-30-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-30\" value=\"two\" id=\"forminator-field-radio-30-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-30-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-32\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-32-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-32-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous \u00e9t\u00e9 hospitalis\u00e9 au cours de la derni\u00e8re ann\u00e9e? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-32-label-1\" for=\"forminator-field-radio-32-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-32\" value=\"one\" id=\"forminator-field-radio-32-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-32-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-32-label-2\" for=\"forminator-field-radio-32-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-32\" value=\"two\" id=\"forminator-field-radio-32-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-32-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-9\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-9_6a23d3df6f82e\" id=\"forminator-field-textarea-9_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer<\/label><textarea name=\"textarea-9\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-9_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-35\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-35-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-35-6a23d3df6f82e-label\" class=\"forminator-label\">Fumez-vous? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-35-label-1\" for=\"forminator-field-radio-35-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-35\" value=\"one\" id=\"forminator-field-radio-35-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-35-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-35-label-2\" for=\"forminator-field-radio-35-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-35\" value=\"two\" id=\"forminator-field-radio-35-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-35-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-12\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-12_6a23d3df6f82e\" id=\"forminator-field-textarea-12_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez indiquer la fr\u00e9quence :<\/label><textarea name=\"textarea-12\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-12_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-33\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-33-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-33-6a23d3df6f82e-label\" class=\"forminator-label\">Consommez-vous de l&#039;alcool ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-33-label-1\" for=\"forminator-field-radio-33-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-33\" value=\"one\" id=\"forminator-field-radio-33-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-33-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-33-label-2\" for=\"forminator-field-radio-33-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-33\" value=\"two\" id=\"forminator-field-radio-33-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-33-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-10\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10_6a23d3df6f82e\" id=\"forminator-field-textarea-10_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez indiquer la fr\u00e9quence :<\/label><textarea name=\"textarea-10\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-10_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-34\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-34-6a23d3df6f82e-label\"><span id=\"forminator-radiogroup-radio-34-6a23d3df6f82e-label\" class=\"forminator-label\">Avez-vous des probl\u00e8mes de sant\u00e9 mentale? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-34-label-1\" for=\"forminator-field-radio-34-1-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-34\" value=\"one\" id=\"forminator-field-radio-34-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-34-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-34-label-2\" for=\"forminator-field-radio-34-2-6a23d3df6f82e\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-34\" value=\"two\" id=\"forminator-field-radio-34-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-radio-34-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"textarea-11\" class=\"forminator-field-textarea forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-11_6a23d3df6f82e\" id=\"forminator-field-textarea-11_6a23d3df6f82e-label\" class=\"forminator-label\">Si vous avez r\u00e9pondu \u00ab Oui \u00bb \u00e0 la question pr\u00e9c\u00e9dente, veuillez expliquer<\/label><textarea name=\"textarea-11\" placeholder=\"Par exemple, espace r\u00e9serv\u00e9 au texte. Vous pouvez ajouter une nouvelle ligne.\" id=\"forminator-field-textarea-11_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_6a23d3df6f82e\" id=\"forminator-field-textarea-7_6a23d3df6f82e-label\" class=\"forminator-label\">Y a-t-il d\u2019autres informations pertinentes sur votre sant\u00e9 que vous souhaitez fournir ?<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_6a23d3df6f82e\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" aria-describedby=\"forminator-field-textarea-7_6a23d3df6f82e-description\" ><\/textarea><span id=\"forminator-field-textarea-7_6a23d3df6f82e-description\" class=\"forminator-description\">Toutes les informations que vous fournissez dans ce formulaire resteront confidentielles et utilis\u00e9es uniquement \u00e0 des fins d&#039;\u00e9valuation m\u00e9dicale. Nous nous engageons \u00e0 prot\u00e9ger votre vie priv\u00e9e et \u00e0 garantir la s\u00e9curit\u00e9 de vos informations personnelles.<\/span><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-4747--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-4747--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"Page 2\"\n\t\t\t\tdata-actual-label=\"Page 3\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">D\u00e9tails finaux et pr\u00e9f\u00e9rences pour votre proc\u00e9dure<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a23d3df6f82e\" id=\"forminator-field-date-2-picker_6a23d3df6f82e-label\" class=\"forminator-label\">Quelle est la date d&#039;intervention souhait\u00e9e ?<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choisir une date\" id=\"forminator-field-date-2-picker_6a23d3df6f82e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a23d3df6f82e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a23d3df6f82e-label\" class=\"forminator-label\">Lequel de ces services compl\u00e9mentaires souhaitez-vous\u00a0?<\/span><label id=\"forminator-field-checkbox-2-1-6a23d3df6f82e-label\" for=\"forminator-field-checkbox-2-1-6a23d3df6f82e\" class=\"forminator-checkbox\" title=\"R\u00e9servation d&#039;h\u00f4tel\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a23d3df6f82e\" aria-labelledby=\"forminator-field-checkbox-2-1-6a23d3df6f82e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">R\u00e9servation d&#039;h\u00f4tel<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a23d3df6f82e-label\" for=\"forminator-field-checkbox-2-2-6a23d3df6f82e\" class=\"forminator-checkbox\" title=\"Prise en charge \u00e0 l&#039;a\u00e9roport\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a23d3df6f82e\" aria-labelledby=\"forminator-field-checkbox-2-2-6a23d3df6f82e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Prise en charge \u00e0 l&#039;a\u00e9roport<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6a23d3df6f82e-label\" for=\"forminator-field-checkbox-2-3-6a23d3df6f82e\" class=\"forminator-checkbox\" title=\"Aucun d&#039;entre eux\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"None-of-Them\" id=\"forminator-field-checkbox-2-3-6a23d3df6f82e\" aria-labelledby=\"forminator-field-checkbox-2-3-6a23d3df6f82e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Aucun d&#039;entre eux<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a23d3df6f82e\" id=\"forminator-field-text-7_6a23d3df6f82e-label\" class=\"forminator-label\">Quelle est votre choix de devise pour les paiements et la r\u00e9ception des devis ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"Par exemple, USD, EUR, GBP, etc.\" id=\"forminator-field-text-7_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-4\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-4_6a23d3df6f82e\" id=\"forminator-field-number-4_6a23d3df6f82e-label\" class=\"forminator-label\">Pourriez-vous s\u2019il vous pla\u00eet partager votre budget estim\u00e9 pour la proc\u00e9dure ? <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-4\" value=\"\" placeholder=\"Par exemple 6 000 EUR, 7 500 USD, 9 500 CAD\" id=\"forminator-field-number-4_6a23d3df6f82e\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"0\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"500000000\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_6a23d3df6f82e\" id=\"forminator-field-text-10_6a23d3df6f82e-label\" class=\"forminator-label\">Comment avez-vous entendu parler de nous?<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"Exemple : r\u00e9f\u00e9rencement, m\u00e9dias sociaux, site Web, etc.\" id=\"forminator-field-text-10_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a23d3df6f82e\" id=\"forminator-field-name-2_6a23d3df6f82e-label\" class=\"forminator-label\">Pour b\u00e9n\u00e9ficier de la r\u00e9duction 5%, veuillez fournir le nom et le pr\u00e9nom du patient r\u00e9f\u00e9rent, le cas \u00e9ch\u00e9ant.<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"Par exemple, John Doe\" id=\"forminator-field-name-2_6a23d3df6f82e\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-2_6a23d3df6f82e-description\" \/><span id=\"forminator-field-name-2_6a23d3df6f82e-description\" class=\"forminator-description\">Sinon, veuillez ignorer cette question<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a23d3df6f82e\" id=\"forminator-field-upload-1_6a23d3df6f82e-label\" class=\"forminator-label\">Veuillez t\u00e9l\u00e9charger les photos et vid\u00e9os de la partie du corps que vous devez traiter. <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-multi-upload\" data-element=\"upload-1_6a23d3df6f82e\" aria-describedby=\"forminator-field-upload-1_6a23d3df6f82e-description\"><input type=\"file\" name=\"upload-1[]\" id=\"forminator-field-upload-1_6a23d3df6f82e\" class=\"forminator-input-file-required do-validate forminator-field-upload-1_6a23d3df6f82e-4747\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"500000000\" data-size-message=\"Maximum file size allowed is 500 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Glissez et d\u00e9posez (ou) <a class=\"forminator-upload-file--forminator-field-upload-1_6a23d3df6f82e\" href=\"#\" onclick=\"return false;\">Choisissez des fichiers<\/a><\/p><\/div><\/div><span id=\"forminator-field-upload-1_6a23d3df6f82e-description\" class=\"forminator-description\">Pour une \u00e9valuation optimale, veuillez soumettre des photos ou des vid\u00e9os bien \u00e9clair\u00e9es \u00e0 360 degr\u00e9s prises uniquement en sous-v\u00eatements. Cela aidera notre m\u00e9decin \u00e0 \u00e9valuer efficacement votre aptitude \u00e0 subir une intervention chirurgicale. Assurez-vous que votre visage n&#039;est pas visible. Dans le cas d&#039;interventions corporelles, \u00e9vitez de couvrir la zone abdominale. (Les images ou vid\u00e9os envoy\u00e9es pour les demandes de chirurgie mammaire doivent \u00eatre prises sans soutien-gorge). Les images ne seront vues et conserv\u00e9es en toute s\u00e9curit\u00e9 que par notre m\u00e9decin. La protection de votre vie priv\u00e9e et de vos informations personnelles est tr\u00e8s importante pour nous, et nous respectons strictement toutes les lois applicables en mati\u00e8re de protection des donn\u00e9es. (Veuillez laisser vide si non applicable)<\/span><ul class=\"forminator-uploaded-files upload-container-upload-1_6a23d3df6f82e\"><\/ul><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled><span class=\"forminator-button--mask\" aria-label=\"cach\u00e9\"><\/span><span class=\"forminator-button--text\">Soumettez le formulaire maintenant<\/span><\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"90a8c598be\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/1156\" \/><input type=\"hidden\" name=\"form_id\" value=\"4747\"><input type=\"hidden\" name=\"page_id\" value=\"1156\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/malikabaci.com\/fr\/online-consultation\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"forminator-multifile-hidden\" class=\"forminator-multifile-hidden\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>obtenir un devis<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_theme","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"unboxed","site-sidebar-style":"unboxed","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-1156","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.2 - 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