{"id":44358,"date":"2026-07-08T10:46:53","date_gmt":"2026-07-08T14:46:53","guid":{"rendered":"https:\/\/guinardetcohen.com\/?page_id=44358"},"modified":"2026-07-08T15:34:23","modified_gmt":"2026-07-08T19:34:23","slug":"enregistrement","status":"publish","type":"page","link":"https:\/\/guinardetcohen.com\/fr\/enregistrement\/","title":{"rendered":"Enregistrement"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"44358\" class=\"elementor 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\">Enregistrement du patient<\/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>\u00a0Veuillez remplir ce formulaire afin de nous aider \u00e0 cr\u00e9\u00e9r votre dossier patient.<\/p><p><em>Tous les renseignements sont confidentiels.<\/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;44353&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-44353 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-44353\" data-uid=\"6a664effb8ae0\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-44353\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-44353 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=\"44353\"\n\t\t\t\t data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a664effb8ae0\"\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_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-name-1_6a664effb8ae0-label\" class=\"forminator-label\">Nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-name-2_6a664effb8ae0-label\" class=\"forminator-label\">Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-date-1-picker_6a664effb8ae0-label\" class=\"forminator-label\">Date de naissance<\/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=\"S\u00e9lectionner une date\" id=\"forminator-field-date-1-picker_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-text-1_6a664effb8ae0-label\" class=\"forminator-label\">RAMQ<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-text-5_6a664effb8ae0-label\" class=\"forminator-label\">Date de expiration<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"AAAA MM\" id=\"forminator-field-text-5_6a664effb8ae0\" 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>Num\u00e9ro d\u2019assurance maladie (Seulement pour les personnes de 17 ans et moins ou 65 ans et plus et consultation urgence)<\/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_6a664effb8ae0\" id=\"forminator-field-address-1-street_address_6a664effb8ae0-label\" class=\"forminator-label\">Adresse<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a664effb8ae0\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" 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_6a664effb8ae0\" id=\"forminator-field-text-2_6a664effb8ae0-label\" class=\"forminator-label\">Ville<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-text-4_6a664effb8ae0-label\" class=\"forminator-label\">Province<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-text-3_6a664effb8ae0-label\" class=\"forminator-label\">Code postal<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-email-1_6a664effb8ae0-label\" class=\"forminator-label\">Courriel<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-phone-2_6a664effb8ae0-label\" class=\"forminator-label\">T\u00e9l\u00e9phone domicile<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a664effb8ae0\" 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_6a664effb8ae0\" id=\"forminator-field-phone-1_6a664effb8ae0-label\" class=\"forminator-label\">Cellulaire<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a664effb8ae0\" 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-1-6a664effb8ae0-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a664effb8ae0-label\" class=\"forminator-label\">Mode de communication privil\u00e9gi\u00e9<\/span><label id=\"forminator-field-checkbox-1-1-6a664effb8ae0-label\" for=\"forminator-field-checkbox-1-1-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Appel t\u00e9l\u00e9phonique\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"appel\" id=\"forminator-field-checkbox-1-1-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-1-1-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Appel t\u00e9l\u00e9phonique<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a664effb8ae0-label\" for=\"forminator-field-checkbox-1-2-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"SMS\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"sms\" id=\"forminator-field-checkbox-1-2-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-1-2-6a664effb8ae0-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-1-3-6a664effb8ae0-label\" for=\"forminator-field-checkbox-1-3-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Courriel\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"courriel\" id=\"forminator-field-checkbox-1-3-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-1-3-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Courriel<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a664effb8ae0-label\" for=\"forminator-field-checkbox-1-4-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Carton de rappel\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"carton\" id=\"forminator-field-checkbox-1-4-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-1-4-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Carton de rappel<\/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-2-6a664effb8ae0-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a664effb8ae0-label\" class=\"forminator-label\">De quelle fa\u00e7on avez-vous connu nos services?<\/span><label id=\"forminator-field-checkbox-2-1-6a664effb8ae0-label\" for=\"forminator-field-checkbox-2-1-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Google\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"google\" id=\"forminator-field-checkbox-2-1-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-2-1-6a664effb8ae0-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-2-2-6a664effb8ae0-label\" for=\"forminator-field-checkbox-2-2-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Clic Sant\u00e9\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"clicsante\" id=\"forminator-field-checkbox-2-2-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-2-2-6a664effb8ae0-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-2-3-6a664effb8ae0-label\" for=\"forminator-field-checkbox-2-3-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Facebook\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"facebook\" id=\"forminator-field-checkbox-2-3-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-2-3-6a664effb8ae0-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-2-4-6a664effb8ae0-label\" for=\"forminator-field-checkbox-2-4-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Instagram\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"instagram\" id=\"forminator-field-checkbox-2-4-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-2-4-6a664effb8ae0-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-2-5-6a664effb8ae0-label\" for=\"forminator-field-checkbox-2-5-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"En marchant\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"marchant\" id=\"forminator-field-checkbox-2-5-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-2-5-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">En marchant<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6a664effb8ae0-label\" for=\"forminator-field-checkbox-2-6-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Bouche \u00e0 oreille\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"bouche\" id=\"forminator-field-checkbox-2-6-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-2-6-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Bouche \u00e0 oreille<\/span><\/label><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-field-checkbox-2-6-6a664effb8ae0\" name=\"custom-checkbox-2\" aria-labelledby=\"forminator-field-checkbox-2-6-6a664effb8ae0-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\">Questionnaire optom\u00e9trique<\/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-3-6a664effb8ae0-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6a664effb8ae0-label\" class=\"forminator-label\">Quelle est la raison de votre visite?<\/span><label id=\"forminator-field-checkbox-3-1-6a664effb8ae0-label\" for=\"forminator-field-checkbox-3-1-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Examen de routine\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"examen-de-routine\" id=\"forminator-field-checkbox-3-1-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-3-1-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Examen de routine<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6a664effb8ae0-label\" for=\"forminator-field-checkbox-3-2-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Changement de vision\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"changement-de-vision\" id=\"forminator-field-checkbox-3-2-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-3-2-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Changement de vision<\/span><\/label><label id=\"forminator-field-checkbox-3-3-6a664effb8ae0-label\" for=\"forminator-field-checkbox-3-3-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Veut changer de monture\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"veut-changer-de-monture\" id=\"forminator-field-checkbox-3-3-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-3-3-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Veut changer de monture<\/span><\/label><label id=\"forminator-field-checkbox-3-4-6a664effb8ae0-label\" for=\"forminator-field-checkbox-3-4-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Renouvellement de lentilles corn\u00e9enes\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"renouvellement-de-lentilles-corneenes\" id=\"forminator-field-checkbox-3-4-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-3-4-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Renouvellement de lentilles corn\u00e9enes<\/span><\/label><label id=\"forminator-field-checkbox-3-5-6a664effb8ae0-label\" for=\"forminator-field-checkbox-3-5-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"R\u00e9f\u00e9rence d&#039;un autre docteur\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"reference-dun-autre-docteur\" id=\"forminator-field-checkbox-3-5-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-3-5-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">R\u00e9f\u00e9rence d'un autre docteur<\/span><\/label><label id=\"forminator-field-checkbox-3-6-6a664effb8ae0-label\" for=\"forminator-field-checkbox-3-6-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Renouvellement permis de conduire\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"renouvellement-permis-conduire\" id=\"forminator-field-checkbox-3-6-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-3-6-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Renouvellement permis de conduire<\/span><\/label><label id=\"forminator-field-checkbox-3-7-6a664effb8ae0-label\" for=\"forminator-field-checkbox-3-7-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Urgence oculaire\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"urgence\" id=\"forminator-field-checkbox-3-7-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-3-7-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Urgence oculaire<\/span><\/label><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-field-checkbox-3-7-6a664effb8ae0\" name=\"custom-checkbox-3\" aria-labelledby=\"forminator-field-checkbox-3-7-6a664effb8ae0-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-1-6a664effb8ae0-label\"><span id=\"forminator-radiogroup-radio-1-6a664effb8ae0-label\" class=\"forminator-label\">\u00c0 quand remonte votre dernier examen visuel?<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a664effb8ae0\" class=\"forminator-radio\" title=\"Premier examen\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a664effb8ae0\" 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\">Premier examen<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a664effb8ae0\" class=\"forminator-radio\" title=\"1 an\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a664effb8ae0\" 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 an<\/span><\/label><label id=\"forminator-field-radio-1-label-3\" for=\"forminator-field-radio-1-3-6a664effb8ae0\" class=\"forminator-radio\" title=\"2 - 3 ans\"><input type=\"radio\" name=\"radio-1\" value=\"2---3-years\" id=\"forminator-field-radio-1-3-6a664effb8ae0\" 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 ans<\/span><\/label><label id=\"forminator-field-radio-1-label-4\" for=\"forminator-field-radio-1-4-6a664effb8ae0\" class=\"forminator-radio\" title=\"4 - 5 ans\"><input type=\"radio\" name=\"radio-1\" value=\"4---5-years\" id=\"forminator-field-radio-1-4-6a664effb8ae0\" 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 ans<\/span><\/label><label id=\"forminator-field-radio-1-label-5\" for=\"forminator-field-radio-1-5-6a664effb8ae0\" class=\"forminator-radio\" title=\"5 - 10 ans\"><input type=\"radio\" name=\"radio-1\" value=\"5---10-years\" id=\"forminator-field-radio-1-5-6a664effb8ae0\" 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 ans<\/span><\/label><label id=\"forminator-field-radio-1-label-6\" for=\"forminator-field-radio-1-6-6a664effb8ae0\" class=\"forminator-radio\" title=\"plus de 10 ans\"><input type=\"radio\" name=\"radio-1\" value=\"more-than-10-years\" id=\"forminator-field-radio-1-6-6a664effb8ae0\" 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\">plus de 10 ans<\/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\">Histoire de cas<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6  form-control\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a664effb8ae0-label\"><span id=\"forminator-radiogroup-radio-2-6a664effb8ae0-label\" class=\"forminator-label\">Portez-vous de lunettes?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a664effb8ae0\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-2\" value=\"lunettes-oui\" id=\"forminator-field-radio-2-1-6a664effb8ae0\" 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-2-2-6a664effb8ae0\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-2\" value=\"lunettes-non\" id=\"forminator-field-radio-2-2-6a664effb8ae0\" 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=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6  form-control\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a664effb8ae0-label\"><span id=\"forminator-radiogroup-radio-3-6a664effb8ae0-label\" class=\"forminator-label\">Avez-vous l&#039;intention de changer vos lunettes?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a664effb8ae0\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-3\" value=\"changer-lunettes-oui\" id=\"forminator-field-radio-3-1-6a664effb8ae0\" 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-3-2-6a664effb8ae0\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-3\" value=\"changer-lunettes-non\" id=\"forminator-field-radio-3-2-6a664effb8ae0\" 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><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-6a664effb8ae0\" class=\"forminator-radio\" title=\"Selon le changement de prescription\"><input type=\"radio\" name=\"radio-3\" value=\"selon-changement-prescription\" id=\"forminator-field-radio-3-3-6a664effb8ae0\" 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\">Selon le changement de prescription<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-6  form-control\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a664effb8ae0-label\"><span id=\"forminator-radiogroup-radio-4-6a664effb8ae0-label\" class=\"forminator-label\">Portez-vous de lentilles corn\u00e9ennes?<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a664effb8ae0\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-4\" value=\"verres-contacts-oui\" id=\"forminator-field-radio-4-1-6a664effb8ae0\" 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-4-2-6a664effb8ae0\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-4\" value=\"verres-contacts-non\" id=\"forminator-field-radio-4-2-6a664effb8ae0\" 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=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-6  form-control\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a664effb8ae0-label\"><span id=\"forminator-radiogroup-radio-5-6a664effb8ae0-label\" class=\"forminator-label\">Avez-vous l&#039;intention de porter des verres de contacts?<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a664effb8ae0\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-5\" value=\"porter-verres-contacts-oui\" id=\"forminator-field-radio-5-1-6a664effb8ae0\" 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-5-2-6a664effb8ae0\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-5\" value=\"porter-verres-contacts-non\" id=\"forminator-field-radio-5-2-6a664effb8ae0\" 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><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-4-6a664effb8ae0-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-6a664effb8ae0-label\" class=\"forminator-label\">Avez-vous \u00e9prouv\u00e9 certaines probl\u00e8mes avec vos yeux?<\/span><span id=\"forminator-field-checkbox-4-6a664effb8ae0-description\" class=\"forminator-description\">Cocher la case correspondante<\/span><label id=\"forminator-field-checkbox-4-1-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-1-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Vision embrouill\u00e9e\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-1-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Vision embrouill\u00e9e<\/span><\/label><label id=\"forminator-field-checkbox-4-2-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-2-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Perte de vision\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-2-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Perte de vision<\/span><\/label><label id=\"forminator-field-checkbox-4-3-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-3-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Vision double\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Double-vision\" id=\"forminator-field-checkbox-4-3-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-3-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Vision double<\/span><\/label><label id=\"forminator-field-checkbox-4-4-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-4-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Fatigue oculaire\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Eye-fatigue\" id=\"forminator-field-checkbox-4-4-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-4-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fatigue oculaire<\/span><\/label><label id=\"forminator-field-checkbox-4-5-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-5-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"\u00c9clairs - Corps flottants\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Flashes-or-floaters\" id=\"forminator-field-checkbox-4-5-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-5-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">\u00c9clairs - Corps flottants<\/span><\/label><label id=\"forminator-field-checkbox-4-6-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-6-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Halo - \u00c9blouissement - Sensibilit\u00e9 \u00e0 la lumi\u00e8re\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Halo,-glare-or-sensitivity-to-light\" id=\"forminator-field-checkbox-4-6-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-6-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Halo - \u00c9blouissement - Sensibilit\u00e9 \u00e0 la lumi\u00e8re<\/span><\/label><label id=\"forminator-field-checkbox-4-7-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-7-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Yeux secs - sensation de sable\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Dry-eyes,-sandy-feeling\" id=\"forminator-field-checkbox-4-7-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-7-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yeux secs - sensation de sable<\/span><\/label><label id=\"forminator-field-checkbox-4-8-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-8-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Yeux qui brulent\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Burning-eyes\" id=\"forminator-field-checkbox-4-8-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-8-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yeux qui brulent<\/span><\/label><label id=\"forminator-field-checkbox-4-9-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-9-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Yeux qui piquent\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Itchy-eyes\" id=\"forminator-field-checkbox-4-9-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-9-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Yeux qui piquent<\/span><\/label><label id=\"forminator-field-checkbox-4-10-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-10-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Larmoiement excessif\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Excessive-tears\" id=\"forminator-field-checkbox-4-10-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-10-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Larmoiement excessif<\/span><\/label><label id=\"forminator-field-checkbox-4-11-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-11-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"S\u00e9cr\u00e9tions, mucus\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Discharge-or-mucus\" id=\"forminator-field-checkbox-4-11-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-11-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">S\u00e9cr\u00e9tions, mucus<\/span><\/label><label id=\"forminator-field-checkbox-4-12-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-12-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Kystes, chalazion ou orgelets\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Inflammation-of-eyelids\" id=\"forminator-field-checkbox-4-12-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-12-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kystes, chalazion ou orgelets<\/span><\/label><label id=\"forminator-field-checkbox-4-13-6a664effb8ae0-label\" for=\"forminator-field-checkbox-4-13-6a664effb8ae0\" class=\"forminator-checkbox\" title=\"Cysts, chalazion or styes\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Cysts,-chalazion-or-styes\" id=\"forminator-field-checkbox-4-13-6a664effb8ae0\" aria-labelledby=\"forminator-field-checkbox-4-13-6a664effb8ae0-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-4-6a664effb8ae0-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\">Lettre de consentement et de divulgation en lien avec la confidentialit\u00e9 (Loi 25)<\/h2><\/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>Cher patient(e),<\/strong><\/p>\n<p>Nous vous remercions de nous faire confiance lors de votre visite pour obtenir des soins visuels. Nous consid\u00e9rons qu\u2019il s\u2019agit d\u2019un privil\u00e8ge de vous fournir les meilleurs soins et nous nous effor\u00e7ons toujours de maintenir votre confiance. Pour maintenir votre confiance, nous devons notamment nous assurer que vous connaissiez la fa\u00e7on dont nous utilisons et prot\u00e9geons vos renseignements personnels.<\/p>\n<p><strong> Loi 25<\/strong><\/p>\n<p>La loi 25 du Qu\u00e9bec est la nouvelle loi stricte (ou loi modernisant des dispositions l\u00e9gislatives en mati\u00e8re de protection des renseignements personnels) qui refl\u00e8te les efforts du Qu\u00e9bec pour moderniser le contexte de la protection de la vie priv\u00e9e et elle est la premi\u00e8re loi de ce type au Canada. Cette loi impose diverses nouvelles obligations aux entreprises en mati\u00e8re de protection des renseignements personnels des r\u00e9sidents du Qu\u00e9bec.<\/p>\n<p><strong> Notre centre<\/strong><\/p>\n<p>Au centre de vision Guinard et Cohen, tous les services oculaires sont fournis par des professionnels, en r\u00e8gle de l\u2019Ordre des optom\u00e9tristes du Qu\u00e9bec. Nous travaillons en partenariat avec les cliniques d\u2019ophtalmologie et les d\u00e9partements d\u2019ophtalmologie des H\u00f4pitaux du Qu\u00e9bec. Nous pourrions devoir leur transmettre vos informations. Vous pourriez nous demander de vous envoyer votre ordonnance, photo fond d\u2019\u0153il, factures par courriel. Tous les services de soutien du centre sont fournis sous la supervision et le contr\u00f4le du responsable de la protection de vos renseignements personnels. Notre syst\u00e8me informatique est s\u00e9v\u00e8rement prot\u00e9g\u00e9 et les dossiers de papiers de nos patients qui ne reviennent pas apr\u00e8s 5 ans sont d\u00e9truits.<\/p>\n<p>Par votre signature, vous reconnaissez que vous avez lu et compris les renseignements fournis dans cette politique et que vous consentez aux pratiques qu\u2019elle d\u00e9crit. 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Tous les renseignements sont confidentiels.<\/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-44358","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>Enregistrement - 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\/fr\/enregistrement\/\" \/>\n<meta property=\"og:locale\" content=\"fr_CA\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Enregistrement - Centre de Vision Guinard &amp; Cohen\" \/>\n<meta property=\"og:description\" content=\"Enregistrement du patient \u00a0Veuillez remplir ce formulaire afin de nous aider \u00e0 cr\u00e9\u00e9r votre dossier patient. 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