{"id":3394,"date":"2020-04-29T00:38:40","date_gmt":"2020-04-29T00:38:40","guid":{"rendered":"https:\/\/lescliniquestoro.com\/?page_id=3394"},"modified":"2022-03-14T22:25:37","modified_gmt":"2022-03-14T22:25:37","slug":"appointment-for-the-toro-dental-clinics","status":"publish","type":"page","link":"https:\/\/lescliniquestoro.com\/en\/appointment-for-the-toro-dental-clinics\/","title":{"rendered":"Appointment for the Toro Dental Clinics"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.4.5&#8243; custom_padding=&#8221;25px||42px|||&#8221; bottom_divider_style=&#8221;curve&#8221; bottom_divider_color=&#8221;#dfedf7&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.4.5&#8243; custom_padding=&#8221;10px||4px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.4.5&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.4.6&#8243; header_2_font=&#8221;Oswald||on|on|||||&#8221; header_2_text_align=&#8221;center&#8221; header_2_text_color=&#8221;#ffffff&#8221; header_2_font_size=&#8221;18px&#8221; background_color=&#8221;#0e5aa8&#8243; width=&#8221;15%&#8221; width_tablet=&#8221;&#8221; width_phone=&#8221;30%&#8221; width_last_edited=&#8221;on|phone&#8221; custom_margin=&#8221;||0px||false|false&#8221; header_2_font_size_tablet=&#8221;22px&#8221; header_2_font_size_phone=&#8221;12px&#8221; header_2_font_size_last_edited=&#8221;on|phone&#8221; border_radii=&#8221;on|15px|15px|15px|15px&#8221; box_shadow_style=&#8221;preset2&#8243; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h2>APPOINTMENTS<\/h2>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.4.5&#8243; background_color=&#8221;#dfedf7&#8243; custom_padding=&#8221;11px|||||&#8221; bottom_divider_style=&#8221;curve&#8221; bottom_divider_color=&#8221;#043f7c&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.4.4&#8243; custom_padding=&#8221;8px|||||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.4.4&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.14.9&#8243; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<p>If <strong>you do not have a file<\/strong> in one of our dental clinics and want to make an Appointment for the Toro Dental Clinics <strong>JEAN-TALON<\/strong> or <strong>NOTRE-DAME<\/strong>, please, fill the form below to provide us with some information to help us to open your file and save you time during your visit. <strong>If you already have a file with us, please complete only the top on making appointments.<\/strong> Please note that <strong>fields marked with \u201c*\u201d are required<\/strong>. Any cancellation of an appointment must be submitted no later than 48 hours prior to such appointment (thank you for your understanding). <strong>Your appointment time will be confirmed by our staff. If not available you will be offered options<\/strong>. Thank you for choosing <strong>Les Cliniques Toro.<\/strong><\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.4.4&#8243; header_3_font=&#8221;Oswald||on||||||&#8221; header_3_text_color=&#8221;#0e5aa8&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h3>Appointment for the Toro Dental Clinics ( sending confidential )<\/h3>\n<p>[\/et_pb_text][et_pb_code _builder_version=&#8221;4.4.4&#8243; global_colors_info=&#8221;{}&#8221;]<div id=\"quform-02f504\" class=\"quform quform-2 quform-theme-light quform-support-page-caching\"><form id=\"quform-form-02f504\" class=\"quform-form quform-form-2\" action=\"\/en\/wp-json\/wp\/v2\/pages\/3394#quform-02f504\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:2,&quot;uniqueId&quot;:&quot;02f504&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:[],&quot;dependents&quot;:[],&quot;elementIds&quot;:[],&quot;dependentElementIds&quot;:[],&quot;animate&quot;:true},&quot;currentPageId&quot;:137,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:false,&quot;pages&quot;:[137],&quot;pageProgressType&quot;:&quot;numbers&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-plain qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-2\"><input type=\"hidden\" name=\"quform_form_id\" value=\"2\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"02f504\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/lescliniquestoro.com\/en\/wp-json\/wp\/v2\/pages\/3394\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"137\" \/><input type=\"hidden\" name=\"quform_loaded\" value=\"1776209435|e48fd3b83e7da01274cac613b388b919\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"wobrbmFVXm4CHWgsgL2I2qT7bZcZHLGTrK9zgpXZ\" \/><div class=\"quform-elements quform-elements-2 quform-cf\"><div class=\"quform-element quform-element-page quform-page-137 quform-page-2_137 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-text quform-element-2_1 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_1\"><label class=\"quform-label-text\" for=\"quform_2_1_02f504\">Your Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_1\"><div class=\"quform-input quform-input-text quform-input-2_1 quform-cf\"><input type=\"text\" id=\"quform_2_1_02f504\" name=\"quform_2_1\" class=\"quform-field quform-field-text quform-field-2_1 quform-tooltip-hover\" \/><div class=\"quform-tooltip-content\">Veuillez entrer votre pr\u00e9nom et nom<\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-2_851706 quform-sr-only quform-cf\" style=\"clip: rect(1px, 1px, 1px, 1px); clip-path: inset(50%); position: absolute !important; height: 1px; width: 1px; overflow: hidden;\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_851706\"><label class=\"quform-label-text\" for=\"quform_2_851706_02f504\">Phone Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-2_851706\"><textarea id=\"quform_2_851706_02f504\" name=\"quform_2_851706\" class=\"quform-field quform-field-textarea quform-field-2_851706\" tabindex=\"-1\" autocomplete=\"new-password\"><\/textarea><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_2 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_2\"><label class=\"quform-label-text\" for=\"quform_2_2_02f504\">Your Adress<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_2\"><div class=\"quform-input quform-input-text quform-input-2_2 quform-cf\"><input type=\"text\" id=\"quform_2_2_02f504\" name=\"quform_2_2\" class=\"quform-field quform-field-text quform-field-2_2 quform-tooltip-hover\" \/><div class=\"quform-tooltip-content\">Veuillez entrer votre adresse avec code postale<\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_3 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_3\"><label class=\"quform-label-text\" for=\"quform_2_3_02f504\">Home phone<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_3\"><div class=\"quform-input quform-input-text quform-input-2_3 quform-cf\"><input type=\"text\" id=\"quform_2_3_02f504\" name=\"quform_2_3\" class=\"quform-field quform-field-text quform-field-2_3 quform-tooltip-hover\" \/><div class=\"quform-tooltip-content\">Veuillez entrer votre t\u00e9l\u00e9phone avec l'indicatif<\/div><\/div><p class=\"quform-description quform-description-below\">If your cell number is your primary phone, please, enter it here<\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_4 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_4\"><label class=\"quform-label-text\" for=\"quform_2_4_02f504\">Work or Cell Phone (with extension) <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_4\"><div class=\"quform-input quform-input-text quform-input-2_4 quform-cf\"><input type=\"text\" id=\"quform_2_4_02f504\" name=\"quform_2_4\" class=\"quform-field quform-field-text quform-field-2_4 quform-tooltip-hover\" \/><div class=\"quform-tooltip-content\">Veuillez entrer votre t\u00e9l\u00e9phone avec l'indicatif<\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-2_5 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_5\"><label class=\"quform-label-text\" id=\"quform_2_5_02f504_label\">Phone confirmation for my appointment:<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-2_5\"><div class=\"quform-input quform-input-checkbox quform-input-2_5 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_2_5_02f504_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_5[]\" id=\"quform_2_5_02f504_1\" class=\"quform-field quform-field-checkbox quform-field-2_5 quform-field-2_5_1\" value=\"Yes\" \/><label for=\"quform_2_5_02f504_1\" class=\"quform-option-label quform-option-label-2_5_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-2_6 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_6\"><label class=\"quform-label-text\" for=\"quform_2_6_02f504\">Your e-mail<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-2_6\"><div class=\"quform-input quform-input-email quform-input-2_6 quform-cf\"><input type=\"email\" id=\"quform_2_6_02f504\" name=\"quform_2_6\" class=\"quform-field quform-field-email quform-field-2_6 quform-tooltip-hover\" \/><div class=\"quform-tooltip-content\">Veuillez entrer votre courriel<\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-date quform-element-2_7 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_7\"><label class=\"quform-label-text\" for=\"quform_2_7_02f504\">Appointment date:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-date quform-inner-2_7\"><div class=\"quform-input quform-input-date quform-input-2_7 quform-cf quform-has-field-icon-right\"><input type=\"text\" id=\"quform_2_7_02f504\" name=\"quform_2_7\" class=\"quform-field quform-field-date quform-field-2_7\" placeholder=\"YYYY-MM-DD\" data-options=\"{&quot;format&quot;:&quot;&quot;,&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;start&quot;:&quot;month&quot;,&quot;depth&quot;:&quot;month&quot;,&quot;showFooter&quot;:false,&quot;locale&quot;:&quot;fr-CA&quot;,&quot;placeholder&quot;:&quot;&quot;,&quot;autoOpen&quot;:true,&quot;identifier&quot;:&quot;2_7&quot;}\" \/><span class=\"quform-field-icon quform-field-icon-right\"><i class=\"qicon-calendar\"><\/i><\/span><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-time quform-element-2_8 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_8\"><label class=\"quform-label-text\" for=\"quform_2_8_02f504\">time of your appointment<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-time quform-inner-2_8\"><div class=\"quform-input quform-input-time quform-input-2_8 quform-cf quform-has-field-icon-right\"><input type=\"text\" id=\"quform_2_8_02f504\" name=\"quform_2_8\" class=\"quform-field quform-field-time quform-field-2_8\" placeholder=\"HH:MM\" data-options=\"{&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;interval&quot;:&quot;1&quot;,&quot;locale&quot;:&quot;fr-CA&quot;,&quot;format&quot;:&quot;&quot;,&quot;placeholder&quot;:&quot;&quot;,&quot;autoOpen&quot;:true,&quot;identifier&quot;:&quot;2_8&quot;}\" value=\"09:00\" \/><span class=\"quform-field-icon quform-field-icon-right\"><i class=\"qicon-schedule\"><\/i><\/span><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_139 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_139\"><label class=\"quform-label-text\" id=\"quform_2_139_02f504_label\">Please, choose your Toro Dental Clinic<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_139\"><div class=\"quform-input quform-input-radio quform-input-2_139 quform-cf\"><div class=\"quform-options quform-cf quform-options-block\" role=\"radiogroup\" aria-labelledby=\"quform_2_139_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_139\" id=\"quform_2_139_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_139 quform-field-2_139_1\" value=\"Toro Dental Clinic Jean-Talon\" \/><label for=\"quform_2_139_02f504_1\" class=\"quform-option-label quform-option-label-2_139_1\"><span class=\"quform-option-icon\"><i class=\"fa fa-hand-o-left\"><\/i><\/span><span class=\"quform-option-icon-selected\"><i class=\"fa fa-thumbs-o-up\"><\/i><\/span><span class=\"quform-option-text\">Toro Dental Clinic Jean-Talon<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_139\" id=\"quform_2_139_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_139 quform-field-2_139_2\" value=\"Toro Dental Clinic Notre-Dame\" \/><label for=\"quform_2_139_02f504_2\" class=\"quform-option-label quform-option-label-2_139_2\"><span class=\"quform-option-icon\"><i class=\"fa fa-hand-o-left\"><\/i><\/span><span class=\"quform-option-icon-selected\"><i class=\"fa fa-thumbs-o-up\"><\/i><\/span><span class=\"quform-option-text\">Toro Dental Clinic Notre-Dame<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_78 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_78\"><label class=\"quform-label-text\" id=\"quform_2_78_02f504_label\">Sex<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_78\"><div class=\"quform-input quform-input-radio quform-input-2_78 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_78_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_78\" id=\"quform_2_78_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_78 quform-field-2_78_1\" value=\"Woman\" \/><label for=\"quform_2_78_02f504_1\" class=\"quform-option-label quform-option-label-2_78_1\"><span class=\"quform-option-text\">Woman<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_78\" id=\"quform_2_78_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_78 quform-field-2_78_2\" value=\"Man\" \/><label for=\"quform_2_78_02f504_2\" class=\"quform-option-label quform-option-label-2_78_2\"><span class=\"quform-option-text\">Man<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-date quform-element-2_10 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_10\"><label class=\"quform-label-text\" for=\"quform_2_10_02f504\"> Date of birth: <\/label><\/div><div class=\"quform-inner quform-inner-date quform-inner-2_10\"><div class=\"quform-input quform-input-date quform-input-2_10 quform-cf quform-has-field-icon-right\"><input type=\"text\" id=\"quform_2_10_02f504\" name=\"quform_2_10\" class=\"quform-field quform-field-date quform-field-2_10\" placeholder=\"YYYY-MM-DD\" data-options=\"{&quot;format&quot;:&quot;&quot;,&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;start&quot;:&quot;month&quot;,&quot;depth&quot;:&quot;month&quot;,&quot;showFooter&quot;:false,&quot;locale&quot;:&quot;fr-CA&quot;,&quot;placeholder&quot;:&quot;&quot;,&quot;autoOpen&quot;:true,&quot;identifier&quot;:&quot;2_10&quot;}\" \/><span class=\"quform-field-icon quform-field-icon-right\"><i class=\"qicon-calendar\"><\/i><\/span><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_79 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_79\"><label class=\"quform-label-text\" id=\"quform_2_79_02f504_label\">Marital status:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_79\"><div class=\"quform-input quform-input-radio quform-input-2_79 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_79_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_79\" id=\"quform_2_79_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_79 quform-field-2_79_1\" value=\"Single\" \/><label for=\"quform_2_79_02f504_1\" class=\"quform-option-label quform-option-label-2_79_1\"><span class=\"quform-option-text\">Single<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_79\" id=\"quform_2_79_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_79 quform-field-2_79_2\" value=\"Married\" \/><label for=\"quform_2_79_02f504_2\" class=\"quform-option-label quform-option-label-2_79_2\"><span class=\"quform-option-text\">Married<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_13 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_13\"><label class=\"quform-label-text\" for=\"quform_2_13_02f504\">Your Wheight: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_13\"><div class=\"quform-input quform-input-text quform-input-2_13 quform-cf\"><input type=\"text\" id=\"quform_2_13_02f504\" name=\"quform_2_13\" class=\"quform-field quform-field-text quform-field-2_13 quform-tooltip-hover\" \/><div class=\"quform-tooltip-content\">Please enter your weight in kg and pounds<\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_14 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_14\"><label class=\"quform-label-text\" for=\"quform_2_14_02f504\">Your Height: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_14\"><div class=\"quform-input quform-input-text quform-input-2_14 quform-cf\"><input type=\"text\" id=\"quform_2_14_02f504\" name=\"quform_2_14\" class=\"quform-field quform-field-text quform-field-2_14 quform-tooltip-hover\" \/><div class=\"quform-tooltip-content\">Please enter your height in meters and feet<\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_80 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_80\"><label class=\"quform-label-text\" id=\"quform_2_80_02f504_label\">I am a customer of Les Cliniques Toro <span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_80\"><div class=\"quform-input quform-input-radio quform-input-2_80 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_80_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_80\" id=\"quform_2_80_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_80 quform-field-2_80_1\" value=\"Yes\" \/><label for=\"quform_2_80_02f504_1\" class=\"quform-option-label quform-option-label-2_80_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_80\" id=\"quform_2_80_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_80 quform-field-2_80_2\" value=\"No\" \/><label for=\"quform_2_80_02f504_2\" class=\"quform-option-label quform-option-label-2_80_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_16 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_16\"><label class=\"quform-label-text\" for=\"quform_2_16_02f504\">Medical Insurance Number (Assurance Maladie):<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_16\"><div class=\"quform-input quform-input-text quform-input-2_16 quform-cf\"><input type=\"text\" id=\"quform_2_16_02f504\" name=\"quform_2_16\" class=\"quform-field quform-field-text quform-field-2_16\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_17 quform-cf quform-labels-inside quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_17\"><label class=\"quform-label-text\" for=\"quform_2_17_02f504\">Expiration:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_17\"><div class=\"quform-input quform-input-text quform-input-2_17 quform-cf\"><input type=\"text\" id=\"quform_2_17_02f504\" name=\"quform_2_17\" class=\"quform-field quform-field-text quform-field-2_17\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_18 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_18\"><label class=\"quform-label-text\" for=\"quform_2_18_02f504\">Financial guardian (if different): <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_18\"><div class=\"quform-input quform-input-text quform-input-2_18 quform-cf\"><input type=\"text\" id=\"quform_2_18_02f504\" name=\"quform_2_18\" class=\"quform-field quform-field-text quform-field-2_18\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_19 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_19\"><label class=\"quform-label-text\" for=\"quform_2_19_02f504\">If a child, name of the parent: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_19\"><div class=\"quform-input quform-input-text quform-input-2_19 quform-cf\"><input type=\"text\" id=\"quform_2_19_02f504\" name=\"quform_2_19\" class=\"quform-field quform-field-text quform-field-2_19\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_20 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_20\"><label class=\"quform-label-text\" for=\"quform_2_20_02f504\">Referred by:<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_20\"><div class=\"quform-input quform-input-text quform-input-2_20 quform-cf\"><input type=\"text\" id=\"quform_2_20_02f504\" name=\"quform_2_20\" class=\"quform-field quform-field-text quform-field-2_20\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-2_21 quform-cf\"><div class=\"quform-spacer\"><h4>INFORMATION ABOUT THE EMPLOYEE INVOLVED IN AN INSURANCE PLAN:<\/h4><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_22 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_22\"><label class=\"quform-label-text\" for=\"quform_2_22_02f504\">Name of the Insurance Company:<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_22\"><div class=\"quform-input quform-input-text quform-input-2_22 quform-cf\"><input type=\"text\" id=\"quform_2_22_02f504\" name=\"quform_2_22\" class=\"quform-field quform-field-text quform-field-2_22\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_23 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_23\"><label class=\"quform-label-text\" for=\"quform_2_23_02f504\">Plan number: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_23\"><div class=\"quform-input quform-input-text quform-input-2_23 quform-cf\"><input type=\"text\" id=\"quform_2_23_02f504\" name=\"quform_2_23\" class=\"quform-field quform-field-text quform-field-2_23\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_24 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_24\"><label class=\"quform-label-text\" for=\"quform_2_24_02f504\">Number of section or division: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_24\"><div class=\"quform-input quform-input-text quform-input-2_24 quform-cf\"><input type=\"text\" id=\"quform_2_24_02f504\" name=\"quform_2_24\" class=\"quform-field quform-field-text quform-field-2_24\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_25 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_25\"><label class=\"quform-label-text\" for=\"quform_2_25_02f504\">Certificate or identity number: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_25\"><div class=\"quform-input quform-input-text quform-input-2_25 quform-cf\"><input type=\"text\" id=\"quform_2_25_02f504\" name=\"quform_2_25\" class=\"quform-field quform-field-text quform-field-2_25\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_26 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_26\"><label class=\"quform-label-text\" for=\"quform_2_26_02f504\">Name of the insured person: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_26\"><div class=\"quform-input quform-input-text quform-input-2_26 quform-cf\"><input type=\"text\" id=\"quform_2_26_02f504\" name=\"quform_2_26\" class=\"quform-field quform-field-text quform-field-2_26\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_81 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_81\"><label class=\"quform-label-text\" id=\"quform_2_81_02f504_label\">Are you covered by an other insurance Plan?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_81\"><div class=\"quform-input quform-input-radio quform-input-2_81 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_81_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_81\" id=\"quform_2_81_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_81 quform-field-2_81_1\" value=\"Yes\" \/><label for=\"quform_2_81_02f504_1\" class=\"quform-option-label quform-option-label-2_81_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_81\" id=\"quform_2_81_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_81 quform-field-2_81_2\" value=\"No\" \/><label for=\"quform_2_81_02f504_2\" class=\"quform-option-label quform-option-label-2_81_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_28 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_28\"><label class=\"quform-label-text\" for=\"quform_2_28_02f504\">If yes, name of the company: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_28\"><div class=\"quform-input quform-input-text quform-input-2_28 quform-cf\"><input type=\"text\" id=\"quform_2_28_02f504\" name=\"quform_2_28\" class=\"quform-field quform-field-text quform-field-2_28\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_29 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_29\"><label class=\"quform-label-text\" for=\"quform_2_29_02f504\">Plan number: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_29\"><div class=\"quform-input quform-input-text quform-input-2_29 quform-cf\"><input type=\"text\" id=\"quform_2_29_02f504\" name=\"quform_2_29\" class=\"quform-field quform-field-text quform-field-2_29\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_30 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_30\"><label class=\"quform-label-text\" for=\"quform_2_30_02f504\">Number of section or division: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_30\"><div class=\"quform-input quform-input-text quform-input-2_30 quform-cf\"><input type=\"text\" id=\"quform_2_30_02f504\" name=\"quform_2_30\" class=\"quform-field quform-field-text quform-field-2_30\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_31 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_31\"><label class=\"quform-label-text\" for=\"quform_2_31_02f504\">Certificate or identity number: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_31\"><div class=\"quform-input quform-input-text quform-input-2_31 quform-cf\"><input type=\"text\" id=\"quform_2_31_02f504\" name=\"quform_2_31\" class=\"quform-field quform-field-text quform-field-2_31\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-2_32 quform-cf\"><div class=\"quform-spacer\"><h4>HELP US TO KNOW YOU BETTER:<\/h4><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_82 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_82\"><label class=\"quform-label-text\" id=\"quform_2_82_02f504_label\">Are you satisfied with the appearance of your teeth?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_82\"><div class=\"quform-input quform-input-radio quform-input-2_82 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_82_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_82\" id=\"quform_2_82_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_82 quform-field-2_82_1\" value=\"Yes\" \/><label for=\"quform_2_82_02f504_1\" class=\"quform-option-label quform-option-label-2_82_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_82\" id=\"quform_2_82_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_82 quform-field-2_82_2\" value=\"No\" \/><label for=\"quform_2_82_02f504_2\" class=\"quform-option-label quform-option-label-2_82_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_83 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_83\"><label class=\"quform-label-text\" id=\"quform_2_83_02f504_label\">worried about financial means required for a treatment?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_83\"><div class=\"quform-input quform-input-radio quform-input-2_83 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_83_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_83\" id=\"quform_2_83_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_83 quform-field-2_83_1\" value=\"Yes\" \/><label for=\"quform_2_83_02f504_1\" class=\"quform-option-label quform-option-label-2_83_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_83\" id=\"quform_2_83_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_83 quform-field-2_83_2\" value=\"No\" \/><label for=\"quform_2_83_02f504_2\" class=\"quform-option-label quform-option-label-2_83_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_84 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_84\"><label class=\"quform-label-text\" id=\"quform_2_84_02f504_label\">disappointed because you have to receive new treatments?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_84\"><div class=\"quform-input quform-input-radio quform-input-2_84 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_84_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_84\" id=\"quform_2_84_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_84 quform-field-2_84_1\" value=\"Yes\" \/><label for=\"quform_2_84_02f504_1\" class=\"quform-option-label quform-option-label-2_84_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_84\" id=\"quform_2_84_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_84 quform-field-2_84_2\" value=\"No\" \/><label for=\"quform_2_84_02f504_2\" class=\"quform-option-label quform-option-label-2_84_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_85 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_85\"><label class=\"quform-label-text\" id=\"quform_2_85_02f504_label\">Do you feel compelled to wear artificial dentures one day?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_85\"><div class=\"quform-input quform-input-radio quform-input-2_85 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_85_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_85\" id=\"quform_2_85_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_85 quform-field-2_85_1\" value=\"Yes\" \/><label for=\"quform_2_85_02f504_1\" class=\"quform-option-label quform-option-label-2_85_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_85\" id=\"quform_2_85_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_85 quform-field-2_85_2\" value=\"No\" \/><label for=\"quform_2_85_02f504_2\" class=\"quform-option-label quform-option-label-2_85_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_119 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_119\"><label class=\"quform-label-text\" id=\"quform_2_119_02f504_label\">Have you of fears in front of dentist?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_119\"><div class=\"quform-input quform-input-radio quform-input-2_119 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_119_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_119\" id=\"quform_2_119_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_119 quform-field-2_119_1\" value=\"Yes\" \/><label for=\"quform_2_119_02f504_1\" class=\"quform-option-label quform-option-label-2_119_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_119\" id=\"quform_2_119_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_119 quform-field-2_119_2\" value=\"No\" \/><label for=\"quform_2_119_02f504_2\" class=\"quform-option-label quform-option-label-2_119_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-2_38 quform-cf\"><div class=\"quform-spacer\"><h4>MEDICAL HISTORY<\/h4><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_86 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_86\"><label class=\"quform-label-text\" id=\"quform_2_86_02f504_label\">Are you currently under the care of a doctor?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_86\"><div class=\"quform-input quform-input-radio quform-input-2_86 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_86_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_86\" id=\"quform_2_86_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_86 quform-field-2_86_1\" value=\"Yes\" \/><label for=\"quform_2_86_02f504_1\" class=\"quform-option-label quform-option-label-2_86_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_86\" id=\"quform_2_86_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_86 quform-field-2_86_2\" value=\"No\" \/><label for=\"quform_2_86_02f504_2\" class=\"quform-option-label quform-option-label-2_86_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_40 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_40\"><label class=\"quform-label-text\" for=\"quform_2_40_02f504\">If yes, give the name of your doctor here: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_40\"><div class=\"quform-input quform-input-text quform-input-2_40 quform-cf\"><input type=\"text\" id=\"quform_2_40_02f504\" name=\"quform_2_40\" class=\"quform-field quform-field-text quform-field-2_40\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_41 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_41\"><label class=\"quform-label-text\" for=\"quform_2_41_02f504\">Phone of your doctor ( with extension): <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_41\"><div class=\"quform-input quform-input-text quform-input-2_41 quform-cf\"><input type=\"text\" id=\"quform_2_41_02f504\" name=\"quform_2_41\" class=\"quform-field quform-field-text quform-field-2_41\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_87 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_87\"><label class=\"quform-label-text\" id=\"quform_2_87_02f504_label\">Currently taking medications or during last 6 months?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_87\"><div class=\"quform-input quform-input-radio quform-input-2_87 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_87_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_87\" id=\"quform_2_87_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_87 quform-field-2_87_1\" value=\"Yes\" \/><label for=\"quform_2_87_02f504_1\" class=\"quform-option-label quform-option-label-2_87_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_87\" id=\"quform_2_87_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_87 quform-field-2_87_2\" value=\"No\" \/><label for=\"quform_2_87_02f504_2\" class=\"quform-option-label quform-option-label-2_87_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-2_43 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_43\"><label class=\"quform-label-text\" for=\"quform_2_43_02f504\">If yes, please indicate which: <\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-2_43\"><div class=\"quform-input quform-input-text quform-input-2_43 quform-cf\"><input type=\"text\" id=\"quform_2_43_02f504\" name=\"quform_2_43\" class=\"quform-field quform-field-text quform-field-2_43\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_88 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_88\"><label class=\"quform-label-text\" id=\"quform_2_88_02f504_label\">Are you pregnant?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_88\"><div class=\"quform-input quform-input-radio quform-input-2_88 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_88_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_88\" id=\"quform_2_88_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_88 quform-field-2_88_1\" value=\"Yes\" \/><label for=\"quform_2_88_02f504_1\" class=\"quform-option-label quform-option-label-2_88_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_88\" id=\"quform_2_88_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_88 quform-field-2_88_2\" value=\"No\" \/><label for=\"quform_2_88_02f504_2\" class=\"quform-option-label quform-option-label-2_88_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_89 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_89\"><label class=\"quform-label-text\" id=\"quform_2_89_02f504_label\">Are you taking oral contraceptives pills?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_89\"><div class=\"quform-input quform-input-radio quform-input-2_89 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_89_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_89\" id=\"quform_2_89_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_89 quform-field-2_89_1\" value=\"Yes\" \/><label for=\"quform_2_89_02f504_1\" class=\"quform-option-label quform-option-label-2_89_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_89\" id=\"quform_2_89_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_89 quform-field-2_89_2\" value=\"No\" \/><label for=\"quform_2_89_02f504_2\" class=\"quform-option-label quform-option-label-2_89_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-2_46 quform-cf\"><div class=\"quform-spacer\"><h4>HAVE YOU EVER SUFFERED OR ARE YOU SUFFERING FROM:<\/h4><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_90 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_90\"><label class=\"quform-label-text\" id=\"quform_2_90_02f504_label\">Cardiac problems (infarctus, angina, valves, respiratory)?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_90\"><div class=\"quform-input quform-input-radio quform-input-2_90 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_90_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_90\" id=\"quform_2_90_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_90 quform-field-2_90_1\" value=\"Yes\" \/><label for=\"quform_2_90_02f504_1\" class=\"quform-option-label quform-option-label-2_90_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_90\" id=\"quform_2_90_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_90 quform-field-2_90_2\" value=\"No\" \/><label for=\"quform_2_90_02f504_2\" class=\"quform-option-label quform-option-label-2_90_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_91 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_91\"><label class=\"quform-label-text\" id=\"quform_2_91_02f504_label\">Rheumatic fever?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_91\"><div class=\"quform-input quform-input-radio quform-input-2_91 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_91_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_91\" id=\"quform_2_91_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_91 quform-field-2_91_1\" value=\"Yes\" \/><label for=\"quform_2_91_02f504_1\" class=\"quform-option-label quform-option-label-2_91_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_91\" id=\"quform_2_91_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_91 quform-field-2_91_2\" value=\"No\" \/><label for=\"quform_2_91_02f504_2\" class=\"quform-option-label quform-option-label-2_91_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_92 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_92\"><label class=\"quform-label-text\" id=\"quform_2_92_02f504_label\">Prolonged bleeding?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_92\"><div class=\"quform-input quform-input-radio quform-input-2_92 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_92_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_92\" id=\"quform_2_92_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_92 quform-field-2_92_1\" value=\"Yes\" \/><label for=\"quform_2_92_02f504_1\" class=\"quform-option-label quform-option-label-2_92_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_92\" id=\"quform_2_92_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_92 quform-field-2_92_2\" value=\"No\" \/><label for=\"quform_2_92_02f504_2\" class=\"quform-option-label quform-option-label-2_92_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_93 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_93\"><label class=\"quform-label-text\" id=\"quform_2_93_02f504_label\">Anemia?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_93\"><div class=\"quform-input quform-input-radio quform-input-2_93 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_93_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_93\" id=\"quform_2_93_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_93 quform-field-2_93_1\" value=\"Yes\" \/><label for=\"quform_2_93_02f504_1\" class=\"quform-option-label quform-option-label-2_93_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_93\" id=\"quform_2_93_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_93 quform-field-2_93_2\" value=\"No\" \/><label for=\"quform_2_93_02f504_2\" class=\"quform-option-label quform-option-label-2_93_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_94 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_94\"><label class=\"quform-label-text\" id=\"quform_2_94_02f504_label\">Arterial tension?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_94\"><div class=\"quform-input quform-input-radio quform-input-2_94 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_94_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_94\" id=\"quform_2_94_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_94 quform-field-2_94_1\" value=\"Yes\" \/><label for=\"quform_2_94_02f504_1\" class=\"quform-option-label quform-option-label-2_94_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_94\" id=\"quform_2_94_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_94 quform-field-2_94_2\" value=\"No\" \/><label for=\"quform_2_94_02f504_2\" class=\"quform-option-label quform-option-label-2_94_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_95 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_95\"><label class=\"quform-label-text\" id=\"quform_2_95_02f504_label\">Frequents colds or sinus infections?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_95\"><div class=\"quform-input quform-input-radio quform-input-2_95 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_95_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_95\" id=\"quform_2_95_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_95 quform-field-2_95_1\" value=\"Yes\" \/><label for=\"quform_2_95_02f504_1\" class=\"quform-option-label quform-option-label-2_95_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_95\" id=\"quform_2_95_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_95 quform-field-2_95_2\" value=\"No\" \/><label for=\"quform_2_95_02f504_2\" class=\"quform-option-label quform-option-label-2_95_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_96 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_96\"><label class=\"quform-label-text\" id=\"quform_2_96_02f504_label\">Tuberculosis or pulmonary problems?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_96\"><div class=\"quform-input quform-input-radio quform-input-2_96 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_96_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_96\" id=\"quform_2_96_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_96 quform-field-2_96_1\" value=\"Yes\" \/><label for=\"quform_2_96_02f504_1\" class=\"quform-option-label quform-option-label-2_96_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_96\" id=\"quform_2_96_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_96 quform-field-2_96_2\" value=\"No\" \/><label for=\"quform_2_96_02f504_2\" class=\"quform-option-label quform-option-label-2_96_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_97 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_97\"><label class=\"quform-label-text\" id=\"quform_2_97_02f504_label\">Digestive problems?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_97\"><div class=\"quform-input quform-input-radio quform-input-2_97 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_97_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_97\" id=\"quform_2_97_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_97 quform-field-2_97_1\" value=\"Yes\" \/><label for=\"quform_2_97_02f504_1\" class=\"quform-option-label quform-option-label-2_97_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_97\" id=\"quform_2_97_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_97 quform-field-2_97_2\" value=\"No\" \/><label for=\"quform_2_97_02f504_2\" class=\"quform-option-label quform-option-label-2_97_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_98 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_98\"><label class=\"quform-label-text\" id=\"quform_2_98_02f504_label\">Stomach ulcer?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_98\"><div class=\"quform-input quform-input-radio quform-input-2_98 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_98_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_98\" id=\"quform_2_98_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_98 quform-field-2_98_1\" value=\"Yes\" \/><label for=\"quform_2_98_02f504_1\" class=\"quform-option-label quform-option-label-2_98_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_98\" id=\"quform_2_98_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_98 quform-field-2_98_2\" value=\"No\" \/><label for=\"quform_2_98_02f504_2\" class=\"quform-option-label quform-option-label-2_98_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_99 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_99\"><label class=\"quform-label-text\" id=\"quform_2_99_02f504_label\">Liver problems ( Hepatitis A, B, C or cirrhosis?): <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_99\"><div class=\"quform-input quform-input-radio quform-input-2_99 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_99_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_99\" id=\"quform_2_99_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_99 quform-field-2_99_1\" value=\"Yes\" \/><label for=\"quform_2_99_02f504_1\" class=\"quform-option-label quform-option-label-2_99_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_99\" id=\"quform_2_99_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_99 quform-field-2_99_2\" value=\"No\" \/><label for=\"quform_2_99_02f504_2\" class=\"quform-option-label quform-option-label-2_99_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_100 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_100\"><label class=\"quform-label-text\" id=\"quform_2_100_02f504_label\">Kidney problems?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_100\"><div class=\"quform-input quform-input-radio quform-input-2_100 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_100_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_100\" id=\"quform_2_100_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_100 quform-field-2_100_1\" value=\"Yes\" \/><label for=\"quform_2_100_02f504_1\" class=\"quform-option-label quform-option-label-2_100_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_100\" id=\"quform_2_100_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_100 quform-field-2_100_2\" value=\"No\" \/><label for=\"quform_2_100_02f504_2\" class=\"quform-option-label quform-option-label-2_100_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_101 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_101\"><label class=\"quform-label-text\" id=\"quform_2_101_02f504_label\">Venereal diseases (STDs)?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_101\"><div class=\"quform-input quform-input-radio quform-input-2_101 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_101_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_101\" id=\"quform_2_101_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_101 quform-field-2_101_1\" value=\"Yes\" \/><label for=\"quform_2_101_02f504_1\" class=\"quform-option-label quform-option-label-2_101_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_101\" id=\"quform_2_101_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_101 quform-field-2_101_2\" value=\"No\" \/><label for=\"quform_2_101_02f504_2\" class=\"quform-option-label quform-option-label-2_101_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_102 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_102\"><label class=\"quform-label-text\" id=\"quform_2_102_02f504_label\">Diabetes?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_102\"><div class=\"quform-input quform-input-radio quform-input-2_102 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_102_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_102\" id=\"quform_2_102_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_102 quform-field-2_102_1\" value=\"Yes\" \/><label for=\"quform_2_102_02f504_1\" class=\"quform-option-label quform-option-label-2_102_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_102\" id=\"quform_2_102_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_102 quform-field-2_102_2\" value=\"No\" \/><label for=\"quform_2_102_02f504_2\" class=\"quform-option-label quform-option-label-2_102_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_103 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_103\"><label class=\"quform-label-text\" id=\"quform_2_103_02f504_label\">Thyroid problems?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_103\"><div class=\"quform-input quform-input-radio quform-input-2_103 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_103_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_103\" id=\"quform_2_103_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_103 quform-field-2_103_1\" value=\"Yes\" \/><label for=\"quform_2_103_02f504_1\" class=\"quform-option-label quform-option-label-2_103_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_103\" id=\"quform_2_103_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_103 quform-field-2_103_2\" value=\"No\" \/><label for=\"quform_2_103_02f504_2\" class=\"quform-option-label quform-option-label-2_103_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_104 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_104\"><label class=\"quform-label-text\" id=\"quform_2_104_02f504_label\">Skin diseases?:  <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_104\"><div class=\"quform-input quform-input-radio quform-input-2_104 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_104_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_104\" id=\"quform_2_104_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_104 quform-field-2_104_1\" value=\"Yes\" \/><label for=\"quform_2_104_02f504_1\" class=\"quform-option-label quform-option-label-2_104_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_104\" id=\"quform_2_104_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_104 quform-field-2_104_2\" value=\"No\" \/><label for=\"quform_2_104_02f504_2\" class=\"quform-option-label quform-option-label-2_104_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_105 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_105\"><label class=\"quform-label-text\" id=\"quform_2_105_02f504_label\">Ocular problems ( eyes)?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_105\"><div class=\"quform-input quform-input-radio quform-input-2_105 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_105_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_105\" id=\"quform_2_105_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_105 quform-field-2_105_1\" value=\"Yes\" \/><label for=\"quform_2_105_02f504_1\" class=\"quform-option-label quform-option-label-2_105_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_105\" id=\"quform_2_105_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_105 quform-field-2_105_2\" value=\"No\" \/><label for=\"quform_2_105_02f504_2\" class=\"quform-option-label quform-option-label-2_105_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_106 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_106\"><label class=\"quform-label-text\" id=\"quform_2_106_02f504_label\">Arthritis?:  <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_106\"><div class=\"quform-input quform-input-radio quform-input-2_106 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_106_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_106\" id=\"quform_2_106_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_106 quform-field-2_106_1\" value=\"Yes\" \/><label for=\"quform_2_106_02f504_1\" class=\"quform-option-label quform-option-label-2_106_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_106\" id=\"quform_2_106_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_106 quform-field-2_106_2\" value=\"No\" \/><label for=\"quform_2_106_02f504_2\" class=\"quform-option-label quform-option-label-2_106_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_107 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_107\"><label class=\"quform-label-text\" id=\"quform_2_107_02f504_label\">Epilepsy?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_107\"><div class=\"quform-input quform-input-radio quform-input-2_107 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_107_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_107\" id=\"quform_2_107_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_107 quform-field-2_107_1\" value=\"Yes\" \/><label for=\"quform_2_107_02f504_1\" class=\"quform-option-label quform-option-label-2_107_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_107\" id=\"quform_2_107_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_107 quform-field-2_107_2\" value=\"No\" \/><label for=\"quform_2_107_02f504_2\" class=\"quform-option-label quform-option-label-2_107_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_108 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_108\"><label class=\"quform-label-text\" id=\"quform_2_108_02f504_label\">Nervous?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_108\"><div class=\"quform-input quform-input-radio quform-input-2_108 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_108_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_108\" id=\"quform_2_108_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_108 quform-field-2_108_1\" value=\"Yes\" \/><label for=\"quform_2_108_02f504_1\" class=\"quform-option-label quform-option-label-2_108_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_108\" id=\"quform_2_108_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_108 quform-field-2_108_2\" value=\"No\" \/><label for=\"quform_2_108_02f504_2\" class=\"quform-option-label quform-option-label-2_108_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_109 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_109\"><label class=\"quform-label-text\" id=\"quform_2_109_02f504_label\">Frequent headaches?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_109\"><div class=\"quform-input quform-input-radio quform-input-2_109 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_109_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_109\" id=\"quform_2_109_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_109 quform-field-2_109_1\" value=\"Yes\" \/><label for=\"quform_2_109_02f504_1\" class=\"quform-option-label quform-option-label-2_109_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_109\" id=\"quform_2_109_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_109 quform-field-2_109_2\" value=\"No\" \/><label for=\"quform_2_109_02f504_2\" class=\"quform-option-label quform-option-label-2_109_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_110 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_110\"><label class=\"quform-label-text\" id=\"quform_2_110_02f504_label\">Dizziness, fainting?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_110\"><div class=\"quform-input quform-input-radio quform-input-2_110 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_110_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_110\" id=\"quform_2_110_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_110 quform-field-2_110_1\" value=\"Yes\" \/><label for=\"quform_2_110_02f504_1\" class=\"quform-option-label quform-option-label-2_110_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_110\" id=\"quform_2_110_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_110 quform-field-2_110_2\" value=\"No\" \/><label for=\"quform_2_110_02f504_2\" class=\"quform-option-label quform-option-label-2_110_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_111 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_111\"><label class=\"quform-label-text\" id=\"quform_2_111_02f504_label\">Ear problems?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_111\"><div class=\"quform-input quform-input-radio quform-input-2_111 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_111_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_111\" id=\"quform_2_111_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_111 quform-field-2_111_1\" value=\"Yes\" \/><label for=\"quform_2_111_02f504_1\" class=\"quform-option-label quform-option-label-2_111_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_111\" id=\"quform_2_111_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_111 quform-field-2_111_2\" value=\"No\" \/><label for=\"quform_2_111_02f504_2\" class=\"quform-option-label quform-option-label-2_111_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_112 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_112\"><label class=\"quform-label-text\" id=\"quform_2_112_02f504_label\">Hay fever: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_112\"><div class=\"quform-input quform-input-radio quform-input-2_112 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_112_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_112\" id=\"quform_2_112_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_112 quform-field-2_112_1\" value=\"Yes\" \/><label for=\"quform_2_112_02f504_1\" class=\"quform-option-label quform-option-label-2_112_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_112\" id=\"quform_2_112_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_112 quform-field-2_112_2\" value=\"No\" \/><label for=\"quform_2_112_02f504_2\" class=\"quform-option-label quform-option-label-2_112_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_113 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_113\"><label class=\"quform-label-text\" id=\"quform_2_113_02f504_label\">Asthma?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_113\"><div class=\"quform-input quform-input-radio quform-input-2_113 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_113_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_113\" id=\"quform_2_113_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_113 quform-field-2_113_1\" value=\"Yes\" \/><label for=\"quform_2_113_02f504_1\" class=\"quform-option-label quform-option-label-2_113_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_113\" id=\"quform_2_113_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_113 quform-field-2_113_2\" value=\"No\" \/><label for=\"quform_2_113_02f504_2\" class=\"quform-option-label quform-option-label-2_113_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_114 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_114\"><label class=\"quform-label-text\" id=\"quform_2_114_02f504_label\">Smoker?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_114\"><div class=\"quform-input quform-input-radio quform-input-2_114 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_114_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_114\" id=\"quform_2_114_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_114 quform-field-2_114_1\" value=\"Yes\" \/><label for=\"quform_2_114_02f504_1\" class=\"quform-option-label quform-option-label-2_114_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_114\" id=\"quform_2_114_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_114 quform-field-2_114_2\" value=\"No\" \/><label for=\"quform_2_114_02f504_2\" class=\"quform-option-label quform-option-label-2_114_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_115 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_115\"><label class=\"quform-label-text\" id=\"quform_2_115_02f504_label\">Have you ever received radiotherapy or chemotherapy?<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_115\"><div class=\"quform-input quform-input-radio quform-input-2_115 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_115_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_115\" id=\"quform_2_115_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_115 quform-field-2_115_1\" value=\"Yes\" \/><label for=\"quform_2_115_02f504_1\" class=\"quform-option-label quform-option-label-2_115_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_115\" id=\"quform_2_115_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_115 quform-field-2_115_2\" value=\"No\" \/><label for=\"quform_2_115_02f504_2\" class=\"quform-option-label quform-option-label-2_115_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_116 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_116\"><label class=\"quform-label-text\" id=\"quform_2_116_02f504_label\">Acquired immune deficiency syndrome (AIDS)?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_116\"><div class=\"quform-input quform-input-radio quform-input-2_116 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_116_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_116\" id=\"quform_2_116_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_116 quform-field-2_116_1\" value=\"Yes\" \/><label for=\"quform_2_116_02f504_1\" class=\"quform-option-label quform-option-label-2_116_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_116\" id=\"quform_2_116_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_116 quform-field-2_116_2\" value=\"No\" \/><label for=\"quform_2_116_02f504_2\" class=\"quform-option-label quform-option-label-2_116_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_117 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_117\"><label class=\"quform-label-text\" id=\"quform_2_117_02f504_label\">Have you tested positive for AIDS?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_117\"><div class=\"quform-input quform-input-radio quform-input-2_117 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_117_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_117\" id=\"quform_2_117_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_117 quform-field-2_117_1\" value=\"Yes\" \/><label for=\"quform_2_117_02f504_1\" class=\"quform-option-label quform-option-label-2_117_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_117\" id=\"quform_2_117_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_117 quform-field-2_117_2\" value=\"No\" \/><label for=\"quform_2_117_02f504_2\" class=\"quform-option-label quform-option-label-2_117_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_118 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_118\"><label class=\"quform-label-text\" id=\"quform_2_118_02f504_label\">Do you have articular prostheses?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_118\"><div class=\"quform-input quform-input-radio quform-input-2_118 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_118_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_118\" id=\"quform_2_118_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_118 quform-field-2_118_1\" value=\"Yes\" \/><label for=\"quform_2_118_02f504_1\" class=\"quform-option-label quform-option-label-2_118_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_118\" id=\"quform_2_118_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_118 quform-field-2_118_2\" value=\"No\" \/><label for=\"quform_2_118_02f504_2\" class=\"quform-option-label quform-option-label-2_118_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-2_77 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_77\"><label class=\"quform-label-text\" id=\"quform_2_77_02f504_label\">Have you ever had a reaction to the following products: <\/label><div class=\"quform-tooltip-icon quform-tooltip-icon-hover\"><i class=\"qicon-question-circle\"><\/i><div class=\"quform-tooltip-icon-content\">Si applicable, vous pouvez faire une ou plusieurs choix<\/div><\/div><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-2_77\"><div class=\"quform-input quform-input-checkbox quform-input-2_77 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"group\" aria-labelledby=\"quform_2_77_02f504_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_1\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_1\" value=\"Food\" \/><label for=\"quform_2_77_02f504_1\" class=\"quform-option-label quform-option-label-2_77_1\"><span class=\"quform-option-text\">Food<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_2\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_2\" value=\"Penicillin\" \/><label for=\"quform_2_77_02f504_2\" class=\"quform-option-label quform-option-label-2_77_2\"><span class=\"quform-option-text\">Penicillin<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_3\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_3\" value=\"Aspirin\" \/><label for=\"quform_2_77_02f504_3\" class=\"quform-option-label quform-option-label-2_77_3\"><span class=\"quform-option-text\">Aspirin<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_4\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_4\" value=\"Iodine\" \/><label for=\"quform_2_77_02f504_4\" class=\"quform-option-label quform-option-label-2_77_4\"><span class=\"quform-option-text\">Iodine<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_5\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_5\" value=\"Sulfonamides\" \/><label for=\"quform_2_77_02f504_5\" class=\"quform-option-label quform-option-label-2_77_5\"><span class=\"quform-option-text\">Sulfonamides<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_6\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_6\" value=\"Codeine\" \/><label for=\"quform_2_77_02f504_6\" class=\"quform-option-label quform-option-label-2_77_6\"><span class=\"quform-option-text\">Codeine<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_7\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_7\" value=\"Local Anesthesia\" \/><label for=\"quform_2_77_02f504_7\" class=\"quform-option-label quform-option-label-2_77_7\"><span class=\"quform-option-text\">Local Anesthesia<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_2_77[]\" id=\"quform_2_77_02f504_8\" class=\"quform-field quform-field-checkbox quform-field-2_77 quform-field-2_77_8\" value=\"Others\" \/><label for=\"quform_2_77_02f504_8\" class=\"quform-option-label quform-option-label-2_77_8\"><span class=\"quform-option-text\">Others<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_120 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_120\"><label class=\"quform-label-text\" id=\"quform_2_120_02f504_label\">Have you ever been hospitalized and \/ or undergone surgery other than dental?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_120\"><div class=\"quform-input quform-input-radio quform-input-2_120 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_120_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_120\" id=\"quform_2_120_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_120 quform-field-2_120_1\" value=\"Yes\" \/><label for=\"quform_2_120_02f504_1\" class=\"quform-option-label quform-option-label-2_120_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_120\" id=\"quform_2_120_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_120 quform-field-2_120_2\" value=\"No\" \/><label for=\"quform_2_120_02f504_2\" class=\"quform-option-label quform-option-label-2_120_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-2_121 quform-cf quform-labels-inside quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_121\"><label class=\"quform-label-text\" for=\"quform_2_121_02f504\">If yes, wich ones and when?: <\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-2_121\"><div class=\"quform-input quform-input-textarea quform-input-2_121 quform-cf\"><textarea id=\"quform_2_121_02f504\" name=\"quform_2_121\" class=\"quform-field quform-field-textarea quform-field-2_121\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_122 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_122\"><label class=\"quform-label-text\" id=\"quform_2_122_02f504_label\">Would you like to privatelly discuss with your dentist?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_122\"><div class=\"quform-input quform-input-radio quform-input-2_122 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_122_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_122\" id=\"quform_2_122_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_122 quform-field-2_122_1\" value=\"Yes\" \/><label for=\"quform_2_122_02f504_1\" class=\"quform-option-label quform-option-label-2_122_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_122\" id=\"quform_2_122_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_122 quform-field-2_122_2\" value=\"No\" \/><label for=\"quform_2_122_02f504_2\" class=\"quform-option-label quform-option-label-2_122_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-2_123 quform-cf\"><div class=\"quform-spacer\"><h4>DENTAL HISTORY:<\/h4><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_124 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_124\"><label class=\"quform-label-text\" id=\"quform_2_124_02f504_label\">last visit to the Dentist:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_124\"><div class=\"quform-input quform-input-radio quform-input-2_124 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_124_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_124\" id=\"quform_2_124_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_124 quform-field-2_124_1\" value=\"0-6 month\" \/><label for=\"quform_2_124_02f504_1\" class=\"quform-option-label quform-option-label-2_124_1\"><span class=\"quform-option-text\">0-6 month<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_124\" id=\"quform_2_124_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_124 quform-field-2_124_2\" value=\"6-12 month\" \/><label for=\"quform_2_124_02f504_2\" class=\"quform-option-label quform-option-label-2_124_2\"><span class=\"quform-option-text\">6-12 month<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_124\" id=\"quform_2_124_02f504_3\" class=\"quform-field quform-field-radio quform-field-2_124 quform-field-2_124_3\" value=\"+ de 12 month\" \/><label for=\"quform_2_124_02f504_3\" class=\"quform-option-label quform-option-label-2_124_3\"><span class=\"quform-option-text\">+ de 12 month<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_125 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_125\"><label class=\"quform-label-text\" id=\"quform_2_125_02f504_label\">Have you ever received an oral hygiene demonstration?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_125\"><div class=\"quform-input quform-input-radio quform-input-2_125 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_125_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_125\" id=\"quform_2_125_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_125 quform-field-2_125_1\" value=\"Yes\" \/><label for=\"quform_2_125_02f504_1\" class=\"quform-option-label quform-option-label-2_125_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_125\" id=\"quform_2_125_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_125 quform-field-2_125_2\" value=\"No\" \/><label for=\"quform_2_125_02f504_2\" class=\"quform-option-label quform-option-label-2_125_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_126 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_126\"><label class=\"quform-label-text\" id=\"quform_2_126_02f504_label\">Have you ever received a Gum treatment?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_126\"><div class=\"quform-input quform-input-radio quform-input-2_126 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_126_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_126\" id=\"quform_2_126_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_126 quform-field-2_126_1\" value=\"Yes\" \/><label for=\"quform_2_126_02f504_1\" class=\"quform-option-label quform-option-label-2_126_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_126\" id=\"quform_2_126_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_126 quform-field-2_126_2\" value=\"No\" \/><label for=\"quform_2_126_02f504_2\" class=\"quform-option-label quform-option-label-2_126_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_127 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_127\"><label class=\"quform-label-text\" id=\"quform_2_127_02f504_label\">Have you had orthodontic treatment (braces)?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_127\"><div class=\"quform-input quform-input-radio quform-input-2_127 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_127_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_127\" id=\"quform_2_127_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_127 quform-field-2_127_1\" value=\"Yes\" \/><label for=\"quform_2_127_02f504_1\" class=\"quform-option-label quform-option-label-2_127_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_127\" id=\"quform_2_127_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_127 quform-field-2_127_2\" value=\"No\" \/><label for=\"quform_2_127_02f504_2\" class=\"quform-option-label quform-option-label-2_127_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_128 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_128\"><label class=\"quform-label-text\" id=\"quform_2_128_02f504_label\">Have you ever received a root canal treatment?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_128\"><div class=\"quform-input quform-input-radio quform-input-2_128 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_128_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_128\" id=\"quform_2_128_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_128 quform-field-2_128_1\" value=\"Yes\" \/><label for=\"quform_2_128_02f504_1\" class=\"quform-option-label quform-option-label-2_128_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_128\" id=\"quform_2_128_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_128 quform-field-2_128_2\" value=\"No\" \/><label for=\"quform_2_128_02f504_2\" class=\"quform-option-label quform-option-label-2_128_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_129 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_129\"><label class=\"quform-label-text\" id=\"quform_2_129_02f504_label\">Have you had fillings (repairs)?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_129\"><div class=\"quform-input quform-input-radio quform-input-2_129 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_129_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_129\" id=\"quform_2_129_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_129 quform-field-2_129_1\" value=\"Yes\" \/><label for=\"quform_2_129_02f504_1\" class=\"quform-option-label quform-option-label-2_129_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_129\" id=\"quform_2_129_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_129 quform-field-2_129_2\" value=\"No\" \/><label for=\"quform_2_129_02f504_2\" class=\"quform-option-label quform-option-label-2_129_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_130 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_130\"><label class=\"quform-label-text\" id=\"quform_2_130_02f504_label\">Crowns and\/or bridges?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_130\"><div class=\"quform-input quform-input-radio quform-input-2_130 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_130_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_130\" id=\"quform_2_130_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_130 quform-field-2_130_1\" value=\"Yes\" \/><label for=\"quform_2_130_02f504_1\" class=\"quform-option-label quform-option-label-2_130_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_130\" id=\"quform_2_130_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_130 quform-field-2_130_2\" value=\"No\" \/><label for=\"quform_2_130_02f504_2\" class=\"quform-option-label quform-option-label-2_130_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_131 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_131\"><label class=\"quform-label-text\" id=\"quform_2_131_02f504_label\">Partial or complete prostheses?:  <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_131\"><div class=\"quform-input quform-input-radio quform-input-2_131 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_131_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_131\" id=\"quform_2_131_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_131 quform-field-2_131_1\" value=\"Yes\" \/><label for=\"quform_2_131_02f504_1\" class=\"quform-option-label quform-option-label-2_131_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_131\" id=\"quform_2_131_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_131 quform-field-2_131_2\" value=\"No\" \/><label for=\"quform_2_131_02f504_2\" class=\"quform-option-label quform-option-label-2_131_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_132 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_132\"><label class=\"quform-label-text\" id=\"quform_2_132_02f504_label\">Dental surgery or extractions?: <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_132\"><div class=\"quform-input quform-input-radio quform-input-2_132 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_132_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_132\" id=\"quform_2_132_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_132 quform-field-2_132_1\" value=\"Yes\" \/><label for=\"quform_2_132_02f504_1\" class=\"quform-option-label quform-option-label-2_132_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_132\" id=\"quform_2_132_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_132 quform-field-2_132_2\" value=\"No\" \/><label for=\"quform_2_132_02f504_2\" class=\"quform-option-label quform-option-label-2_132_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_133 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_133\"><label class=\"quform-label-text\" id=\"quform_2_133_02f504_label\">Dental Implants?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_133\"><div class=\"quform-input quform-input-radio quform-input-2_133 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_133_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_133\" id=\"quform_2_133_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_133 quform-field-2_133_1\" value=\"Yes\" \/><label for=\"quform_2_133_02f504_1\" class=\"quform-option-label quform-option-label-2_133_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_133\" id=\"quform_2_133_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_133 quform-field-2_133_2\" value=\"No\" \/><label for=\"quform_2_133_02f504_2\" class=\"quform-option-label quform-option-label-2_133_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_134 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_134\"><label class=\"quform-label-text\" id=\"quform_2_134_02f504_label\">Dental radiographies?:<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_134\"><div class=\"quform-input quform-input-radio quform-input-2_134 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_134_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_134\" id=\"quform_2_134_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_134 quform-field-2_134_1\" value=\"Yes\" \/><label for=\"quform_2_134_02f504_1\" class=\"quform-option-label quform-option-label-2_134_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_134\" id=\"quform_2_134_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_134 quform-field-2_134_2\" value=\"No\" \/><label for=\"quform_2_134_02f504_2\" class=\"quform-option-label quform-option-label-2_134_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-2_135 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_135\"><label class=\"quform-label-text\" id=\"quform_2_135_02f504_label\">Others? <\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-2_135\"><div class=\"quform-input quform-input-radio quform-input-2_135 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_2_135_02f504_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_135\" id=\"quform_2_135_02f504_1\" class=\"quform-field quform-field-radio quform-field-2_135 quform-field-2_135_1\" value=\"Yes\" \/><label for=\"quform_2_135_02f504_1\" class=\"quform-option-label quform-option-label-2_135_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_2_135\" id=\"quform_2_135_02f504_2\" class=\"quform-field quform-field-radio quform-field-2_135 quform-field-2_135_2\" value=\"No\" \/><label for=\"quform_2_135_02f504_2\" class=\"quform-option-label quform-option-label-2_135_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-recaptcha quform-element-2_140 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-2_140\"><label class=\"quform-label-text\">Are you human ?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-recaptcha quform-inner-2_140\"><div class=\"quform-input quform-input-recaptcha quform-input-2_140 quform-cf\"><div class=\"quform-recaptcha\" data-config=\"{&quot;sitekey&quot;:&quot;6Lc_n8USAAAAAAcp4XsuExyN5aHgcX6r50nXzumV&quot;,&quot;_version&quot;:&quot;v2&quot;,&quot;size&quot;:&quot;normal&quot;,&quot;type&quot;:&quot;image&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;badge&quot;:&quot;bottomright&quot;}\"><\/div><noscript><div><div style=\"width: 302px; height: 422px; position: relative;\"><div style=\"width: 302px; height: 422px; position: absolute;\"><iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6Lc_n8USAAAAAAcp4XsuExyN5aHgcX6r50nXzumV\" frameborder=\"0\" scrolling=\"no\" style=\"width: 302px; height:422px; border-style: none;\"><\/iframe><\/div><\/div><div style=\"width: 300px; height: 60px; border-style: none; bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px; background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px;\"><textarea name=\"g-recaptcha-response\" class=\"g-recaptcha-response\" style=\"width: 250px; height: 40px; border: 1px solid #c1c1c1; margin: 10px 25px; padding: 0px; resize: none;\" aria-hidden=\"true\"><\/textarea><\/div><\/div><\/noscript><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-2_138 quform-cf quform-button-style-theme\"><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-2_138 quform-button-icon-right\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Send<\/span><span class=\"quform-button-icon quform-button-submit-icon\"><i class=\"fa fa-paper-plane\"><\/i><\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div>[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>If you want to schedule an appointment with Toro Dental Clinic Jean-Talon or Toro Dental Clinic Notre-Dame, please, fill the form bellow&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"class_list":["post-3394","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Appointment for the Toro Dental Clinics - Les Cliniques 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