{"id":2188,"date":"2020-05-14T04:53:47","date_gmt":"2020-05-14T00:53:47","guid":{"rendered":"https:\/\/agency.securimed.ca\/?page_id=2188"},"modified":"2020-11-30T21:13:44","modified_gmt":"2020-12-01T02:13:44","slug":"covid-19-med","status":"publish","type":"page","link":"https:\/\/agency.securimed.ca\/en\/covid-19-med\/","title":{"rendered":"COVID-19-med"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_8' style='display:none'><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/en\/wp-json\/wp\/v2\/pages\/2188#gf_8' data-formid='8' novalidate>\n        <div id='gf_progressbar_wrapper_8' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>10<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_10' style='width:10%;'><span>10%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_8_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_17\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Choisir \/ Choose<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_17'>\n\t\t\t<li class='gchoice gchoice_8_17_0'>\n\t\t\t\t<input name='input_17' type='radio' value='Fran\u00e7ais'  id='choice_8_17_0'    \/>\n\t\t\t\t<label for='choice_8_17_0' id='label_8_17_0' class='gform-field-label gform-field-label--type-inline'>Fran\u00e7ais<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_17_1'>\n\t\t\t\t<input name='input_17' type='radio' value='English'  id='choice_8_17_1'    \/>\n\t\t\t\t<label for='choice_8_17_1' id='label_8_17_1' class='gform-field-label gform-field-label--type-inline'>English<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_8_15' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_2' class='gform_page' data-js='page-field-id-15' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_18\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>D\u00e9pistage<\/b><\/p>\n<ul>\n<li> Dans la perspective de la protection de tous, en particulier les personnes qui sont \u00e0 risque. On vous demande de compl\u00e9ter un bilan de votre sant\u00e9 afin de d\u00e9pister les personnes vuln\u00e9rables.<\/li>\n<\/ul>\n<br>\n<p><b>CONFIDENTIALIT\u00c9<\/b><\/p>\n<ul>\n<li>Vos informations sont confidentielles. Nous transmettons \u00e0 votre employeur s'il y un besoin d'avoir une \u00e9valuation plus approfondie dans le cas ou vous avez des facteurs de risque.<\/li>\n<\/ul><\/li><li id=\"field_8_49\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_49'>Code d\u2019identification que vous avez re\u00e7u de votre employeur ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_8_49' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_4\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_4'>Pour quelle entreprise travaillez-vous ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_8_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_19\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_19'>T\u00e9l\u00e9phone ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_8_19' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_2\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Votre nom ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_2'>\n                            \n                            <span id='input_8_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_8_2_3' value=''   aria-required='true'   placeholder='Pr\u00e9nom'  \/>\n                                                    <label for='input_8_2_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_8_2_6' value=''   aria-required='true'   placeholder='Nom'  \/>\n                                                    <label for='input_8_2_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_8_97\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_97'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_97' id='input_8_97' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_97_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_97_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_97' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_84\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>Screening<\/b><\/p>\n<ul>\n<li> From the perspective of the protection of all, especially those who are at risk. You are asked to complete a health check in order to screen for vulnerable people.<\/li>\n<\/ul>\n<br>\n<p><b>CONFIDENTIALITY<\/b><\/p>\n<ul>\n<li>Your information is confidential. We pass on to your employer if there is a need to have a more in-depth assessment in case you have risk factors.<\/li>\n<\/ul><\/li><li id=\"field_8_50\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_50'>Code that you have received from your HR ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_8_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_13\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_13'>What company to you work for ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_8_13' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_20\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_20'>Phone number ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_8_20' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_8_11\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Your name ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_11'>\n                            \n                            <span id='input_8_11_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_11.3' id='input_8_11_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_8_11_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_11_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_11.6' id='input_8_11_6' value=''   aria-required='true'   placeholder='Last name'  \/>\n                                                    <label for='input_8_11_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_8_98\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_98'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_98' id='input_8_98' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_8_98_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_98_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_98' class='gform_hidden' value='https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_57' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_57' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_3' class='gform_page' data-js='page-field-id-57' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">IDENTIFICATION<\/h2><\/li><li id=\"field_8_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >600 : Identifier le groupe d&#039;\u00e2ge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_5'>\n\t\t\t<li class='gchoice gchoice_8_5_0'>\n\t\t\t\t<input name='input_5' type='radio' value='70 ans et plus'  id='choice_8_5_0'    \/>\n\t\t\t\t<label for='choice_8_5_0' id='label_8_5_0' class='gform-field-label gform-field-label--type-inline'>70 ans et plus<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_5_1'>\n\t\t\t\t<input name='input_5' type='radio' value='65 \u00e0 69 ans'  id='choice_8_5_1'    \/>\n\t\t\t\t<label for='choice_8_5_1' id='label_8_5_1' class='gform-field-label gform-field-label--type-inline'>65 \u00e0 69 ans<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_5_2'>\n\t\t\t\t<input name='input_5' type='radio' value='60 \u00e0 64 ans'  id='choice_8_5_2'    \/>\n\t\t\t\t<label for='choice_8_5_2' id='label_8_5_2' class='gform-field-label gform-field-label--type-inline'>60 \u00e0 64 ans<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_5_3'>\n\t\t\t\t<input name='input_5' type='radio' value='Moins de 59 ans'  id='choice_8_5_3'    \/>\n\t\t\t\t<label for='choice_8_5_3' id='label_8_5_3' class='gform-field-label gform-field-label--type-inline'>Moins de 59 ans<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_87\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_87'>601 : Inscrive votre poids en livres<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_87' id='input_8_87' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_8_88\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_88'>602 : Inscrire votre grandeur en pieds et pouces (ex. 5.7)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_88' id='input_8_88' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_8_27\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">IDENTIFICATION<\/h2><\/li><li id=\"field_8_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >600 : Choose the age group ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_21'>\n\t\t\t<li class='gchoice gchoice_8_21_0'>\n\t\t\t\t<input name='input_21' type='radio' value='70 and more'  id='choice_8_21_0'    \/>\n\t\t\t\t<label for='choice_8_21_0' id='label_8_21_0' class='gform-field-label gform-field-label--type-inline'>70 and more<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_21_1'>\n\t\t\t\t<input name='input_21' type='radio' value='65 \u00e0 69 years'  id='choice_8_21_1'    \/>\n\t\t\t\t<label for='choice_8_21_1' id='label_8_21_1' class='gform-field-label gform-field-label--type-inline'>65 \u00e0 69 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_21_2'>\n\t\t\t\t<input name='input_21' type='radio' value='60 \u00e0 64 years'  id='choice_8_21_2'    \/>\n\t\t\t\t<label for='choice_8_21_2' id='label_8_21_2' class='gform-field-label gform-field-label--type-inline'>60 \u00e0 64 years<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_21_3'>\n\t\t\t\t<input name='input_21' type='radio' value='Less than 50 years'  id='choice_8_21_3'    \/>\n\t\t\t\t<label for='choice_8_21_3' id='label_8_21_3' class='gform-field-label gform-field-label--type-inline'>Less than 50 years<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_91\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_91'>601 : Indicate your weight in pounds ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_91' id='input_8_91' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_8_92\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_92'>602 : Indicate your height in feet and inches (ex: 5.7) ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_8_92' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_58' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_58' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_4' class='gform_page' data-js='page-field-id-58' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_28\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">MALADIES<\/h2><\/li><li id=\"field_8_30\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\u00c0 titre informatif, les maladies suivantes ne font partie des maladies \u00e0 risque : Cholest\u00e9rol, glande thyro\u00efde, acide gastrique.<\/li><li id=\"field_8_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >700 : Je dois ou devrais prendre de la m\u00e9dication contre l&#039;hypertension ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_31'>\n\t\t\t<li class='gchoice gchoice_8_31_0'>\n\t\t\t\t<input name='input_31' type='radio' value='Oui'  id='choice_8_31_0'    \/>\n\t\t\t\t<label for='choice_8_31_0' id='label_8_31_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_31_1'>\n\t\t\t\t<input name='input_31' type='radio' value='Non'  id='choice_8_31_1'    \/>\n\t\t\t\t<label for='choice_8_31_1' id='label_8_31_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >701 : Je dois prendre de la m\u00e9dication contre un probl\u00e8me cardiaque ou AVC ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_33'>\n\t\t\t<li class='gchoice gchoice_8_33_0'>\n\t\t\t\t<input name='input_33' type='radio' value='Oui'  id='choice_8_33_0'    \/>\n\t\t\t\t<label for='choice_8_33_0' id='label_8_33_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_33_1'>\n\t\t\t\t<input name='input_33' type='radio' value='Non'  id='choice_8_33_1'    \/>\n\t\t\t\t<label for='choice_8_33_1' id='label_8_33_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >702 : Je dois prendre de la m\u00e9dication pour le diab\u00e8te ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_32'>\n\t\t\t<li class='gchoice gchoice_8_32_0'>\n\t\t\t\t<input name='input_32' type='radio' value='Oui'  id='choice_8_32_0'    \/>\n\t\t\t\t<label for='choice_8_32_0' id='label_8_32_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_32_1'>\n\t\t\t\t<input name='input_32' type='radio' value='Non'  id='choice_8_32_1'    \/>\n\t\t\t\t<label for='choice_8_32_1' id='label_8_32_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_65\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Disease<\/h2><\/li><li id=\"field_8_64\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >In the affirmative, the following diseases are not part of the risk diseases: Cholesterol, thyroid gland, gastric acid.<\/li><li id=\"field_8_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >700 : Am I Should or should I be taking high blood pressure medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_66'>\n\t\t\t<li class='gchoice gchoice_8_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Oui'  id='choice_8_66_0'    \/>\n\t\t\t\t<label for='choice_8_66_0' id='label_8_66_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='Non'  id='choice_8_66_1'    \/>\n\t\t\t\t<label for='choice_8_66_1' id='label_8_66_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >701 : Do I need to take medication for a heart problem or stroke?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_67'>\n\t\t\t<li class='gchoice gchoice_8_67_0'>\n\t\t\t\t<input name='input_67' type='radio' value='Oui'  id='choice_8_67_0'    \/>\n\t\t\t\t<label for='choice_8_67_0' id='label_8_67_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_67_1'>\n\t\t\t\t<input name='input_67' type='radio' value='Non'  id='choice_8_67_1'    \/>\n\t\t\t\t<label for='choice_8_67_1' id='label_8_67_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >702 : Do I need to take diabetes medication?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_68'>\n\t\t\t<li class='gchoice gchoice_8_68_0'>\n\t\t\t\t<input name='input_68' type='radio' value='Oui'  id='choice_8_68_0'    \/>\n\t\t\t\t<label for='choice_8_68_0' id='label_8_68_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_68_1'>\n\t\t\t\t<input name='input_68' type='radio' value='Non'  id='choice_8_68_1'    \/>\n\t\t\t\t<label for='choice_8_68_1' id='label_8_68_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_59' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_5' class='gform_page' data-js='page-field-id-59' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >800 : Je dois prendre de la m\u00e9dication contre : Une maladie pulmonaire, de l&#039;asthme, de l&#039;emphys\u00e8me, une MPOC ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_34'>\n\t\t\t<li class='gchoice gchoice_8_34_0'>\n\t\t\t\t<input name='input_34' type='radio' value='Oui'  id='choice_8_34_0'    \/>\n\t\t\t\t<label for='choice_8_34_0' id='label_8_34_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_34_1'>\n\t\t\t\t<input name='input_34' type='radio' value='Non'  id='choice_8_34_1'    \/>\n\t\t\t\t<label for='choice_8_34_1' id='label_8_34_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >801 : Avez-vous eu une intervention chirurgicale pulmonaire ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_51'>\n\t\t\t<li class='gchoice gchoice_8_51_0'>\n\t\t\t\t<input name='input_51' type='radio' value='Oui'  id='choice_8_51_0'    \/>\n\t\t\t\t<label for='choice_8_51_0' id='label_8_51_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_51_1'>\n\t\t\t\t<input name='input_51' type='radio' value='Non'  id='choice_8_51_1'    \/>\n\t\t\t\t<label for='choice_8_51_1' id='label_8_51_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >802 : Dans les 2 derni\u00e8res ann\u00e9es, avez-vous combattu un cancer ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_39'>\n\t\t\t<li class='gchoice gchoice_8_39_0'>\n\t\t\t\t<input name='input_39' type='radio' value='Oui'  id='choice_8_39_0'    \/>\n\t\t\t\t<label for='choice_8_39_0' id='label_8_39_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_39_1'>\n\t\t\t\t<input name='input_39' type='radio' value='Non'  id='choice_8_39_1'    \/>\n\t\t\t\t<label for='choice_8_39_1' id='label_8_39_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >800 : Do I need to take medication for: A lung disease, Asthma, emphysema, COPD ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_73'>\n\t\t\t<li class='gchoice gchoice_8_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='Oui'  id='choice_8_73_0'    \/>\n\t\t\t\t<label for='choice_8_73_0' id='label_8_73_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='Non'  id='choice_8_73_1'    \/>\n\t\t\t\t<label for='choice_8_73_1' id='label_8_73_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >801 : Have you had lung surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_72'>\n\t\t\t<li class='gchoice gchoice_8_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='Oui'  id='choice_8_72_0'    \/>\n\t\t\t\t<label for='choice_8_72_0' id='label_8_72_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='Non'  id='choice_8_72_1'    \/>\n\t\t\t\t<label for='choice_8_72_1' id='label_8_72_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >802 : In the past 2 years, have you fought cancer ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_74'>\n\t\t\t<li class='gchoice gchoice_8_74_0'>\n\t\t\t\t<input name='input_74' type='radio' value='Oui'  id='choice_8_74_0'    \/>\n\t\t\t\t<label for='choice_8_74_0' id='label_8_74_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_74_1'>\n\t\t\t\t<input name='input_74' type='radio' value='Non'  id='choice_8_74_1'    \/>\n\t\t\t\t<label for='choice_8_74_1' id='label_8_74_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_60' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_60' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_6' class='gform_page' data-js='page-field-id-60' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >900 : Je dois prendre de la m\u00e9dication contre la maladie de Crohn ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_77'>\n\t\t\t<li class='gchoice gchoice_8_77_0'>\n\t\t\t\t<input name='input_77' type='radio' value='Oui'  id='choice_8_77_0'    \/>\n\t\t\t\t<label for='choice_8_77_0' id='label_8_77_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_77_1'>\n\t\t\t\t<input name='input_77' type='radio' value='Non'  id='choice_8_77_1'    \/>\n\t\t\t\t<label for='choice_8_77_1' id='label_8_77_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >901 : Je dois prendre de la m\u00e9dication contre : des maladies inflammatoires et de l&#039;intestin SAUF LE COLON IRRITABLE ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_37'>\n\t\t\t<li class='gchoice gchoice_8_37_0'>\n\t\t\t\t<input name='input_37' type='radio' value='Oui'  id='choice_8_37_0'    \/>\n\t\t\t\t<label for='choice_8_37_0' id='label_8_37_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_37_1'>\n\t\t\t\t<input name='input_37' type='radio' value='Non'  id='choice_8_37_1'    \/>\n\t\t\t\t<label for='choice_8_37_1' id='label_8_37_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >902 : Je dois prendre de la m\u00e9dication immunosuppresseur contre : Arthrite rhumato\u00eede, Polyarthrite, lupus, maladie d&#039;Addison, scl\u00e9rose en plaque, etc. ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_38'>\n\t\t\t<li class='gchoice gchoice_8_38_0'>\n\t\t\t\t<input name='input_38' type='radio' value='Oui'  id='choice_8_38_0'    \/>\n\t\t\t\t<label for='choice_8_38_0' id='label_8_38_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_38_1'>\n\t\t\t\t<input name='input_38' type='radio' value='Non'  id='choice_8_38_1'    \/>\n\t\t\t\t<label for='choice_8_38_1' id='label_8_38_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >900 : Do I need to take medication for Crohn&#039;s disease ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_36'>\n\t\t\t<li class='gchoice gchoice_8_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Oui'  id='choice_8_36_0'    \/>\n\t\t\t\t<label for='choice_8_36_0' id='label_8_36_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='Non'  id='choice_8_36_1'    \/>\n\t\t\t\t<label for='choice_8_36_1' id='label_8_36_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_76\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >901 : I need to take medication for: inflammatory and bowel disease EXCEPT IRRITABLE BOWEL?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_76'>\n\t\t\t<li class='gchoice gchoice_8_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Oui'  id='choice_8_76_0'    \/>\n\t\t\t\t<label for='choice_8_76_0' id='label_8_76_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='Non'  id='choice_8_76_1'    \/>\n\t\t\t\t<label for='choice_8_76_1' id='label_8_76_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_75\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >902 : I need to take immunosuppressive medication for: Rheumatoid arthritis, polyarthritis, lupus, Addison&#039;s disease, multiple sclerosis, etc. ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_75'>\n\t\t\t<li class='gchoice gchoice_8_75_0'>\n\t\t\t\t<input name='input_75' type='radio' value='Oui'  id='choice_8_75_0'    \/>\n\t\t\t\t<label for='choice_8_75_0' id='label_8_75_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_75_1'>\n\t\t\t\t<input name='input_75' type='radio' value='Non'  id='choice_8_75_1'    \/>\n\t\t\t\t<label for='choice_8_75_1' id='label_8_75_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_61' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_61' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_7' class='gform_page' data-js='page-field-id-61' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >950 : Avez-vous une maladie ou une insuffisance r\u00e9nale ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_41'>\n\t\t\t<li class='gchoice gchoice_8_41_0'>\n\t\t\t\t<input name='input_41' type='radio' value='Oui'  id='choice_8_41_0'    \/>\n\t\t\t\t<label for='choice_8_41_0' id='label_8_41_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_41_1'>\n\t\t\t\t<input name='input_41' type='radio' value='Non'  id='choice_8_41_1'    \/>\n\t\t\t\t<label for='choice_8_41_1' id='label_8_41_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >951 : Avez-vous une cirrhose ou une insuffisance h\u00e9patique ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_52'>\n\t\t\t<li class='gchoice gchoice_8_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Oui'  id='choice_8_52_0'    \/>\n\t\t\t\t<label for='choice_8_52_0' id='label_8_52_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='Non'  id='choice_8_52_1'    \/>\n\t\t\t\t<label for='choice_8_52_1' id='label_8_52_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >952 : Avez-vous une maladie sanguine ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_48'>\n\t\t\t<li class='gchoice gchoice_8_48_0'>\n\t\t\t\t<input name='input_48' type='radio' value='Oui'  id='choice_8_48_0'    \/>\n\t\t\t\t<label for='choice_8_48_0' id='label_8_48_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_48_1'>\n\t\t\t\t<input name='input_48' type='radio' value='Non'  id='choice_8_48_1'    \/>\n\t\t\t\t<label for='choice_8_48_1' id='label_8_48_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >950 : Do you have kidney disease or failure?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_80'>\n\t\t\t<li class='gchoice gchoice_8_80_0'>\n\t\t\t\t<input name='input_80' type='radio' value='Oui'  id='choice_8_80_0'    \/>\n\t\t\t\t<label for='choice_8_80_0' id='label_8_80_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_80_1'>\n\t\t\t\t<input name='input_80' type='radio' value='Non'  id='choice_8_80_1'    \/>\n\t\t\t\t<label for='choice_8_80_1' id='label_8_80_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >951 : Do you have cirrhosis or liver failure?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_79'>\n\t\t\t<li class='gchoice gchoice_8_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Oui'  id='choice_8_79_0'    \/>\n\t\t\t\t<label for='choice_8_79_0' id='label_8_79_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='Non'  id='choice_8_79_1'    \/>\n\t\t\t\t<label for='choice_8_79_1' id='label_8_79_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >952 : Do you have a blood disease?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_78'>\n\t\t\t<li class='gchoice gchoice_8_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='Oui'  id='choice_8_78_0'    \/>\n\t\t\t\t<label for='choice_8_78_0' id='label_8_78_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='Non'  id='choice_8_78_1'    \/>\n\t\t\t\t<label for='choice_8_78_1' id='label_8_78_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_62' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_62' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_8' class='gform_page' data-js='page-field-id-62' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >970 : Je souffre de : un trouble cognitif, une le\u0301sion me\u0301dullaire, un trouble convulsif, des troubles neuromusculaires?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_43'>\n\t\t\t<li class='gchoice gchoice_8_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='Oui'  id='choice_8_43_0'    \/>\n\t\t\t\t<label for='choice_8_43_0' id='label_8_43_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='Non'  id='choice_8_43_1'    \/>\n\t\t\t\t<label for='choice_8_43_1' id='label_8_43_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >971 : Avez-vous eu une greffe, SAUF POUR LES GENCIVES ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_46'>\n\t\t\t<li class='gchoice gchoice_8_46_0'>\n\t\t\t\t<input name='input_46' type='radio' value='Oui'  id='choice_8_46_0'    \/>\n\t\t\t\t<label for='choice_8_46_0' id='label_8_46_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_46_1'>\n\t\t\t\t<input name='input_46' type='radio' value='Non'  id='choice_8_46_1'    \/>\n\t\t\t\t<label for='choice_8_46_1' id='label_8_46_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >972: Avez-vous le VIH ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_45'>\n\t\t\t<li class='gchoice gchoice_8_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Oui'  id='choice_8_45_0'    \/>\n\t\t\t\t<label for='choice_8_45_0' id='label_8_45_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='Non'  id='choice_8_45_1'    \/>\n\t\t\t\t<label for='choice_8_45_1' id='label_8_45_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >970 : I suffer from: a cognitive disorder, a spinal cord injury, a convulsive disorder, neuromuscular disorders?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_83'>\n\t\t\t<li class='gchoice gchoice_8_83_0'>\n\t\t\t\t<input name='input_83' type='radio' value='Oui'  id='choice_8_83_0'    \/>\n\t\t\t\t<label for='choice_8_83_0' id='label_8_83_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_83_1'>\n\t\t\t\t<input name='input_83' type='radio' value='Non'  id='choice_8_83_1'    \/>\n\t\t\t\t<label for='choice_8_83_1' id='label_8_83_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >971 : Have you had a transplant, EXCEPT FOR GUMS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_82'>\n\t\t\t<li class='gchoice gchoice_8_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Oui'  id='choice_8_82_0'    \/>\n\t\t\t\t<label for='choice_8_82_0' id='label_8_82_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='Non'  id='choice_8_82_1'    \/>\n\t\t\t\t<label for='choice_8_82_1' id='label_8_82_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >973 : Do you have HIV?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_81'>\n\t\t\t<li class='gchoice gchoice_8_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Oui'  id='choice_8_81_0'    \/>\n\t\t\t\t<label for='choice_8_81_0' id='label_8_81_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='Non'  id='choice_8_81_1'    \/>\n\t\t\t\t<label for='choice_8_81_1' id='label_8_81_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_69' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_69' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_9' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >980 : Apr\u00e8s avoir pris connaissance des facteurs de risque. Selon vous, est-ce que vous vivez avec une personne comportant des facteur de risque ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_96'>\n\t\t\t<li class='gchoice gchoice_8_96_0'>\n\t\t\t\t<input name='input_96' type='radio' value='Oui'  id='choice_8_96_0'    \/>\n\t\t\t\t<label for='choice_8_96_0' id='label_8_96_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_96_1'>\n\t\t\t\t<input name='input_96' type='radio' value='Non'  id='choice_8_96_1'    \/>\n\t\t\t\t<label for='choice_8_96_1' id='label_8_96_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_95\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >980: After knowing the risk factors, According to you, do you live with someone who has risk factors?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_95'>\n\t\t\t<li class='gchoice gchoice_8_95_0'>\n\t\t\t\t<input name='input_95' type='radio' value='Oui'  id='choice_8_95_0'    \/>\n\t\t\t\t<label for='choice_8_95_0' id='label_8_95_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_95_1'>\n\t\t\t\t<input name='input_95' type='radio' value='Non'  id='choice_8_95_1'    \/>\n\t\t\t\t<label for='choice_8_95_1' id='label_8_95_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_94' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='\u2190'  \/> <input type='button' id='gform_next_button_8_94' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='\u2192'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_10' class='gform_page' data-js='page-field-id-94' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_8_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_8_70\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">CONSENTEMENT<\/h2><\/li><li id=\"field_8_63\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>Consentement<\/b><\/p>\n<ul>\n<li> Par ma signature, j\u2019autorise la clinique m\u00e9dicale \u00e0 transmettre au demandeur si mon \u00e9tat de sant\u00e9 n\u00e9cessite une \u00e9valuation m\u00e9dicale plus approfondi en lien avec le COVID-19<\/li>\n<li> Je reconnais que mes r\u00e9ponses serviront \u00e0 identifier mon \u00e9tat de sant\u00e9 en lien avec le COVID-19 en date de la journ\u00e9e et qu'un d\u00e9pistage du risque de contagion sera effectu\u00e9e selon les lignes directrices \u00e9mises par la sant\u00e9 publique, je reconnais que le fait de donner des renseignements faux ou trompeurs pourrait me mettre en danger.<\/li>\n<\/ul><\/li><li id=\"field_8_85\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>Consentry<\/b> <\/p>\n<ul>\n<li> By my signature, I authorize the medical clinic to transmit to the applicant if my state of health requires a more in-depth medical evaluation in connection with COVID-19 <\/li>\n<li> I recognize that my answers will be used to identify my state of health in connection with COVID-19 as of the day and that a screening for the risk of contagion will be carried out according to the guidelines issued by public health, I recognize that giving false or misleading information could endanger me. <\/li>\n<\/ul><\/li><li id=\"field_8_86\" class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_86'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_86' id='input_8_86_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_8_86_Container' class='gfield_signature_container' style='height:180px; width:300px; ' ><canvas id=\"input_8_86\" width=\"300\" height=\"180\" style=\"border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/agency.securimed.ca\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><\/div><div id='input_8_86_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id='input_8_86_resetbutton' 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name='gform_submission_method' data-js='gform_submission_method_8' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_8' id='gform_theme_8' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_8' id='gform_style_settings_8' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_8' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='8' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='fFid2J9ZuUDD93VJclWvsQ2dBSPIISGww8EtYLaHGX6jsPpJsoD7r+bbGAjwRMh4GD3OBrNROlo+ZgEFZ6Dm3jjIWjZeYE3RTZOKgNtJYpcsl4U=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_8' 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