{"id":44359,"date":"2026-07-08T10:46:53","date_gmt":"2026-07-08T14:46:53","guid":{"rendered":"https:\/\/guinardetcohen.com\/?page_id=44359"},"modified":"2026-07-08T14:39:03","modified_gmt":"2026-07-08T18:39:03","slug":"registration","status":"publish","type":"page","link":"https:\/\/guinardetcohen.com\/en\/registration\/","title":{"rendered":"Registration"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"44359\" class=\"elementor elementor-44359 elementor-44358\">\n\t\t\t\t<section class=\"elementor-element elementor-element-48bf120 cmsmasters-section-for-header-yes e-flex e-con-boxed cmsmasters-block-default e-con e-parent\" data-id=\"48bf120\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-e69bbdd e-con-full e-flex cmsmasters-block-default e-con e-child\" data-id=\"e69bbdd\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4da089c cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-heading\" data-id=\"4da089c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Patient registration<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-332d653 cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-text-editor\" data-id=\"332d653\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Please fill out this form to help us start your patient file.<\/p><p><em>All information is confidential.<\/em><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7f97a75 elementor-widget__width-inherit cmsmasters-block-default cmsmasters-sticky-default elementor-widget elementor-widget-cmsmasters-forminator\" data-id=\"7f97a75\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;form_list&quot;:&quot;44352&quot;}\" data-widget_type=\"cmsmasters-forminator.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-widget-cmsmasters-contact-form__wrapper elementor-widget-cmsmasters-contact-form cmsmasters-default-color cmsmasters-default-font\" id=\"cmsmasters-widget-form-7f97a75\">\r\n\t\t\t<div class=\"elementor-widget-cmsmasters-contact-form__inner\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-44352 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-44352\" data-uid=\"6a6660604fe7d\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-44352\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-44352 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"44352\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a6660604fe7d\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row forminator-hidden\"><div id=\"hidden-1\" class=\"forminator-field-hidden  forminator-col-12 \"><input type=\"hidden\" id=\"hidden-1_6a6660604fe7d\" name=\"hidden-1\" value=\"submission_id\" \/><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a6660604fe7d\" id=\"forminator-field-name-1_6a6660604fe7d-label\" class=\"forminator-label\">Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a6660604fe7d\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a6660604fe7d\" id=\"forminator-field-name-2_6a6660604fe7d-label\" class=\"forminator-label\">Surname <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a6660604fe7d\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a6660604fe7d\" id=\"forminator-field-date-1-picker_6a6660604fe7d-label\" class=\"forminator-label\">Date of birth<\/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-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6a6660604fe7d\" 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=\"0\" 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=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a6660604fe7d\" id=\"forminator-field-text-1_6a6660604fe7d-label\" class=\"forminator-label\">RAMQ<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a6660604fe7d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a6660604fe7d\" id=\"forminator-field-text-5_6a6660604fe7d-label\" class=\"forminator-label\">Expiration Date<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a6660604fe7d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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\"><em><small>Health insurance number (Only for people 17 years and under or 65 years and over and emergency consultation)<\/small><\/em><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a6660604fe7d\" id=\"forminator-field-address-1-street_address_6a6660604fe7d-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a6660604fe7d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a6660604fe7d\" id=\"forminator-field-address-1-address_line_6a6660604fe7d-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a6660604fe7d\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a6660604fe7d\" id=\"forminator-field-text-2_6a6660604fe7d-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a6660604fe7d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a6660604fe7d\" id=\"forminator-field-text-4_6a6660604fe7d-label\" class=\"forminator-label\">Province<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a6660604fe7d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a6660604fe7d\" id=\"forminator-field-text-3_6a6660604fe7d-label\" class=\"forminator-label\">Postal Code<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a6660604fe7d\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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_6a6660604fe7d\" id=\"forminator-field-email-1_6a6660604fe7d-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a6660604fe7d\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a6660604fe7d\" id=\"forminator-field-phone-2_6a6660604fe7d-label\" class=\"forminator-label\">Home Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a6660604fe7d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a6660604fe7d\" id=\"forminator-field-phone-1_6a6660604fe7d-label\" class=\"forminator-label\">Cell Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a6660604fe7d\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-6  form-control\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a6660604fe7d-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a6660604fe7d-label\" class=\"forminator-label\">Preferred method of communication<\/span><label id=\"forminator-field-checkbox-1-1-6a6660604fe7d-label\" for=\"forminator-field-checkbox-1-1-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Phone\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"phone\" id=\"forminator-field-checkbox-1-1-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-1-1-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Phone<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a6660604fe7d-label\" for=\"forminator-field-checkbox-1-2-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"SMS\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"sms\" id=\"forminator-field-checkbox-1-2-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-1-2-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">SMS<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a6660604fe7d-label\" for=\"forminator-field-checkbox-1-3-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Email\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"email\" id=\"forminator-field-checkbox-1-3-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-1-3-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Email<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a6660604fe7d-label\" for=\"forminator-field-checkbox-1-4-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Reminder Card\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"card\" id=\"forminator-field-checkbox-1-4-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-1-4-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Reminder Card<\/span><\/label><\/div><\/div><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-6  form-control\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a6660604fe7d-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a6660604fe7d-label\" class=\"forminator-label\">Where did you hear about us?<\/span><label id=\"forminator-field-checkbox-2-1-6a6660604fe7d-label\" for=\"forminator-field-checkbox-2-1-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Google\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"google\" id=\"forminator-field-checkbox-2-1-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-2-1-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Google<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a6660604fe7d-label\" for=\"forminator-field-checkbox-2-2-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Clic Sant\u00e9\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"clicsante\" id=\"forminator-field-checkbox-2-2-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-2-2-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Clic Sant\u00e9<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6a6660604fe7d-label\" for=\"forminator-field-checkbox-2-3-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Facebook\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"facebook\" id=\"forminator-field-checkbox-2-3-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-2-3-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Facebook<\/span><\/label><label id=\"forminator-field-checkbox-2-4-6a6660604fe7d-label\" for=\"forminator-field-checkbox-2-4-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Instagram\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"instagram\" id=\"forminator-field-checkbox-2-4-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-2-4-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Instagram<\/span><\/label><label id=\"forminator-field-checkbox-2-5-6a6660604fe7d-label\" for=\"forminator-field-checkbox-2-5-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Walking\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"walking\" id=\"forminator-field-checkbox-2-5-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-2-5-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Walking<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6a6660604fe7d-label\" for=\"forminator-field-checkbox-2-6-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Word of mouth\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"mouth\" id=\"forminator-field-checkbox-2-6-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-2-6-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Word of mouth<\/span><\/label><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-field-checkbox-2-6-6a6660604fe7d\" name=\"custom-checkbox-2\" aria-labelledby=\"forminator-field-checkbox-2-6-6a6660604fe7d-label\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><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\">Optometry Questionnaire<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-6  form-control\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-6a6660604fe7d-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6a6660604fe7d-label\" class=\"forminator-label\">What is the reason for your visit?<\/span><label id=\"forminator-field-checkbox-3-1-6a6660604fe7d-label\" for=\"forminator-field-checkbox-3-1-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Routine exam\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"routine-exam\" id=\"forminator-field-checkbox-3-1-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-3-1-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Routine exam<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6a6660604fe7d-label\" for=\"forminator-field-checkbox-3-2-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Change in vision\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"change-in-vision\" id=\"forminator-field-checkbox-3-2-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-3-2-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Change in vision<\/span><\/label><label id=\"forminator-field-checkbox-3-3-6a6660604fe7d-label\" for=\"forminator-field-checkbox-3-3-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Want to change frames\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"want-to-change-frames\" id=\"forminator-field-checkbox-3-3-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-3-3-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Want to change frames<\/span><\/label><label id=\"forminator-field-checkbox-3-4-6a6660604fe7d-label\" for=\"forminator-field-checkbox-3-4-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Contact lenses renewal\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"contact-lenses-renewal\" id=\"forminator-field-checkbox-3-4-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-3-4-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Contact lenses renewal<\/span><\/label><label id=\"forminator-field-checkbox-3-5-6a6660604fe7d-label\" for=\"forminator-field-checkbox-3-5-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Referral from another doctor\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"referral-from-another-doctor\" id=\"forminator-field-checkbox-3-5-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-3-5-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Referral from another doctor<\/span><\/label><label id=\"forminator-field-checkbox-3-6-6a6660604fe7d-label\" for=\"forminator-field-checkbox-3-6-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Driving license renewal\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"driving-license-renewal\" id=\"forminator-field-checkbox-3-6-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-3-6-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Driving license renewal<\/span><\/label><label id=\"forminator-field-checkbox-3-7-6a6660604fe7d-label\" for=\"forminator-field-checkbox-3-7-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Eye emergency\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"emergency\" id=\"forminator-field-checkbox-3-7-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-3-7-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Eye emergency<\/span><\/label><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-field-checkbox-3-7-6a6660604fe7d\" name=\"custom-checkbox-3\" aria-labelledby=\"forminator-field-checkbox-3-7-6a6660604fe7d-label\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6  form-control\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a6660604fe7d-label\"><span id=\"forminator-radiogroup-radio-1-6a6660604fe7d-label\" class=\"forminator-label\">When was your last eye exam?<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a6660604fe7d\" class=\"forminator-radio\" title=\"First examination\"><input type=\"radio\" name=\"radio-1\" value=\"first-exam\" id=\"forminator-field-radio-1-1-6a6660604fe7d\" 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\">First examination<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a6660604fe7d\" class=\"forminator-radio\" title=\"1 year\"><input type=\"radio\" name=\"radio-1\" value=\"1-year\" id=\"forminator-field-radio-1-2-6a6660604fe7d\" 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\">1 year<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-6a6660604fe7d\" class=\"forminator-radio\" title=\"2 - 3 years\"><input type=\"radio\" name=\"radio-1\" value=\"2-3-years\" id=\"forminator-field-radio-1-3-6a6660604fe7d\" aria-labelledby=\"forminator-field-radio-1-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">2 - 3 years<\/span><\/label><label id=\"forminator-field-radio-1-label-4\" for=\"forminator-field-radio-1-4-6a6660604fe7d\" class=\"forminator-radio\" title=\"4 - 5 years\"><input type=\"radio\" name=\"radio-1\" value=\"4-5-years\" id=\"forminator-field-radio-1-4-6a6660604fe7d\" aria-labelledby=\"forminator-field-radio-1-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">4 - 5 years<\/span><\/label><label id=\"forminator-field-radio-1-label-5\" for=\"forminator-field-radio-1-5-6a6660604fe7d\" class=\"forminator-radio\" title=\"5 - 10 years\"><input type=\"radio\" name=\"radio-1\" value=\"5-10-years\" id=\"forminator-field-radio-1-5-6a6660604fe7d\" aria-labelledby=\"forminator-field-radio-1-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">5 - 10 years<\/span><\/label><label id=\"forminator-field-radio-1-label-6\" for=\"forminator-field-radio-1-6-6a6660604fe7d\" class=\"forminator-radio\" title=\"more than 10 years\"><input type=\"radio\" name=\"radio-1\" value=\"more-than-10-years\" id=\"forminator-field-radio-1-6-6a6660604fe7d\" aria-labelledby=\"forminator-field-radio-1-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">more than 10 years<\/span><\/label><\/div><\/div><\/div><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\">Clinical History<\/h2><\/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-2-6a6660604fe7d-label\"><span id=\"forminator-radiogroup-radio-2-6a6660604fe7d-label\" class=\"forminator-label\">Do you wear glasses<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a6660604fe7d\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"glasses-yes\" id=\"forminator-field-radio-2-1-6a6660604fe7d\" 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\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a6660604fe7d\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"glasses-no\" id=\"forminator-field-radio-2-2-6a6660604fe7d\" 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\">No<\/span><\/label><\/div><\/div><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a6660604fe7d-label\"><span id=\"forminator-radiogroup-radio-3-6a6660604fe7d-label\" class=\"forminator-label\">Are you interested in changing your glasses?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a6660604fe7d\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"change-glasses-yes\" id=\"forminator-field-radio-3-1-6a6660604fe7d\" 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\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a6660604fe7d\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"change-glasses-no\" id=\"forminator-field-radio-3-2-6a6660604fe7d\" 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\">No<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-6a6660604fe7d\" class=\"forminator-radio\" title=\"Depends on the prescription change\"><input type=\"radio\" name=\"radio-3\" value=\"depends-on-the-prescription-change\" id=\"forminator-field-radio-3-3-6a6660604fe7d\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Depends on the prescription change<\/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-4-6a6660604fe7d-label\"><span id=\"forminator-radiogroup-radio-4-6a6660604fe7d-label\" class=\"forminator-label\">Do you wear contact lenses?<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a6660604fe7d\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"contacts-yes\" id=\"forminator-field-radio-4-1-6a6660604fe7d\" 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\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a6660604fe7d\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"contacts-no\" id=\"forminator-field-radio-4-2-6a6660604fe7d\" 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\">No<\/span><\/label><\/div><\/div><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a6660604fe7d-label\"><span id=\"forminator-radiogroup-radio-5-6a6660604fe7d-label\" class=\"forminator-label\">Are you interested in using contact lenses?<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a6660604fe7d\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"use-contacts-yes\" id=\"forminator-field-radio-5-1-6a6660604fe7d\" 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\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a6660604fe7d\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"use-contacts-no\" id=\"forminator-field-radio-5-2-6a6660604fe7d\" 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\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12  form-control\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-6a6660604fe7d-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-6a6660604fe7d-label\" class=\"forminator-label\">Have you experienced any problems with your eyes?<\/span><span id=\"forminator-field-checkbox-4-6a6660604fe7d-description\" class=\"forminator-description\">Check all that apply<\/span><label id=\"forminator-field-checkbox-4-1-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-1-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Blurred vision\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"blurred-vision\" id=\"forminator-field-checkbox-4-1-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-1-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Blurred vision<\/span><\/label><label id=\"forminator-field-checkbox-4-2-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-2-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Vision loss\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"vision-loss\" id=\"forminator-field-checkbox-4-2-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-2-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Vision loss<\/span><\/label><label id=\"forminator-field-checkbox-4-3-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-3-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Double vision\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"double-vision\" id=\"forminator-field-checkbox-4-3-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-3-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Double vision<\/span><\/label><label id=\"forminator-field-checkbox-4-4-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-4-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Eye fatigue\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"eye-fatigue\" id=\"forminator-field-checkbox-4-4-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-4-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Eye fatigue<\/span><\/label><label id=\"forminator-field-checkbox-4-5-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-5-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Flashes or floaters\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"flashes-or-floaters\" id=\"forminator-field-checkbox-4-5-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-5-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Flashes or floaters<\/span><\/label><label id=\"forminator-field-checkbox-4-6-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-6-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Halo, glare or sensitivity to light\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"halo,-glare-or-sensitivity-to-light\" id=\"forminator-field-checkbox-4-6-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-6-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Halo, glare or sensitivity to light<\/span><\/label><label id=\"forminator-field-checkbox-4-7-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-7-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Dry eyes, sandy feeling\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"dry-eyes,-sandy-feeling\" id=\"forminator-field-checkbox-4-7-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-7-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Dry eyes, sandy feeling<\/span><\/label><label id=\"forminator-field-checkbox-4-8-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-8-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Burning eyes\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"burning-eyes\" id=\"forminator-field-checkbox-4-8-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-8-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Burning eyes<\/span><\/label><label id=\"forminator-field-checkbox-4-9-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-9-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Itchy eyes\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"itchy-eyes\" id=\"forminator-field-checkbox-4-9-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-9-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Itchy eyes<\/span><\/label><label id=\"forminator-field-checkbox-4-10-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-10-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Excessive tears\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"excessive-tears\" id=\"forminator-field-checkbox-4-10-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-10-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Excessive tears<\/span><\/label><label id=\"forminator-field-checkbox-4-11-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-11-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Discharge or mucus\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"discharge-or-mucus\" id=\"forminator-field-checkbox-4-11-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-11-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Discharge or mucus<\/span><\/label><label id=\"forminator-field-checkbox-4-12-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-12-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Inflammation of eyelids\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"inflammation-of-eyelids\" id=\"forminator-field-checkbox-4-12-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-12-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Inflammation of eyelids<\/span><\/label><label id=\"forminator-field-checkbox-4-13-6a6660604fe7d-label\" for=\"forminator-field-checkbox-4-13-6a6660604fe7d\" class=\"forminator-checkbox\" title=\"Cysts, chalazion or styes\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"cysts,-chalazion-or-styes\" id=\"forminator-field-checkbox-4-13-6a6660604fe7d\" aria-labelledby=\"forminator-field-checkbox-4-13-6a6660604fe7d-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a6660604fe7d-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cysts, chalazion or styes<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Letter of consent and disclosure related to confidentiality (Bill 25)<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid 1;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><p><strong>Dear patient<\/strong>,<\/p>\n<p>We thank you for trusting us during your visit to obtain vision care. We consider it a privilege to provide you with the best care and we always strive to maintain your trust. Part of maintaining your trust is ensuring that you are aware of how we use and protect your personal information.<\/p>\n<p><strong>Bill 25<\/strong><\/p>\n<p>Quebec's Bill 25 (Loi 25) is the new strict law (or law modernizing legislative provisions relating to the protection of personal information) which reflects Quebec's efforts to modernize the context of the protection of privacy and it is the first law of this type in Canada. This law imposes various new obligations on companies regarding the protection of the personal information of Quebec residents.<\/p>\n<p><strong>Our center<\/strong><\/p>\n<p>At Guinard &amp; Cohen Vision Center, all eye services are provided by professionals, in good standing with the Order of Optometrists of Quebec. We work in partnership with ophthalmology clinics and ophthalmology departments of Quebec\u2019s hospitals. We may need to pass your information to them. You could ask us to send you your prescription, fundus photo, invoices by email. All support services of the center are provided under the supervision and control of the person responsible for the protection of your personal information. Our computer system is severely protected and the paper files of our patients who do not return after 5 years are destroyed.<\/p>\n<p>By accepting, you acknowledge that you have read and understood the information provided in this policy and that you consent to the practices it describes. Do not hesitate to ask us questions if necessary.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_6a6660604fe7d__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6a6660604fe7d\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6a6660604fe7d-label\" aria-describedby=\"forminator-field-consent-1_6a6660604fe7d__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6a6660604fe7d__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>I accept.<\/p><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"eb19f429a0\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/44359\" \/><input type=\"hidden\" name=\"form_id\" value=\"44352\"><input type=\"hidden\" name=\"page_id\" value=\"44359\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/guinardetcohen.com\/en\/registration\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><label for=\"input_24\" class=\"forminator-hidden\" aria-hidden=\"true\">Please do not fill in this field. <input id=\"input_24\" type=\"text\" name=\"input_24\" value=\"\" autocomplete=\"off\"><\/label><\/form><\/div>\r\n\t\t<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient registration Please fill out this form to help us start your patient file. All information is confidential.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-44359","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Registration - Centre de Vision Guinard &amp; Cohen<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/guinardetcohen.com\/en\/registration\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Registration - Centre de Vision Guinard &amp; Cohen\" \/>\n<meta property=\"og:description\" content=\"Patient registration Please fill out this form to help us start your patient file. 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