{"id":3790,"date":"2021-05-30T20:24:19","date_gmt":"2021-05-31T00:24:19","guid":{"rendered":"https:\/\/www.centredentairegriffin.com\/forms\/dental-form\/"},"modified":"2022-03-14T20:10:18","modified_gmt":"2022-03-15T00:10:18","slug":"formulaire-dentaire","status":"publish","type":"page","link":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/formulaires\/formulaire-dentaire\/","title":{"rendered":"Formulaire dentaire"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:0px;--awb-padding-bottom:40px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1320.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:0%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div ><a class=\"fusion-button button-flat button-xlarge button-custom fusion-button-default button-1 fusion-button-default-span fusion-button-default-type\" style=\"--button_accent_color:#656a70;--button_accent_hover_color:#6b6b6b;--button_border_hover_color:#ffffff;--button_gradient_top_color:rgba(0,0,0,0);--button_gradient_bottom_color:rgba(0,0,0,0);--button_gradient_top_color_hover:rgba(40,45,51,0.1);--button_gradient_bottom_color_hover:rgba(40,45,51,0.1);\" target=\"_self\" href=\"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/formulaires\/\"><i class=\"fa-arrow-left fas awb-button__icon awb-button__icon--default button-icon-left\" aria-hidden=\"true\"><\/i><span class=\"fusion-button-text awb-button__text awb-button__text--default\">RETOURNER AU FORMULAIRES<\/span><\/a><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1320.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:25px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:25px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3940-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3940\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/3790#wpcf7-f3940-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3940\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3940-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:3940,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;show-food-stuck&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-food-stuck&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-filling-fallen&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-filling-fallen&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-gum-bleed&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-gum-bleed&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-family-disease&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-family-disease&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-confident-breath&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-confident-breath&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;non&quot;}]},{&quot;then_field&quot;:&quot;show-restrain-chewing&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-restrain-chewing&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-feel-grind&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-feel-grind&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-feel-not-equal&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-feel-not-equal&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-teeth-worn-out&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-teeth-worn-out&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-jaw-locks&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-jaw-locks&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-sensitive-morning&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-sensitive-morning&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-orthodontic-treatment&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-orthodontic-treatment&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-satisfied-appearance&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-satisfied-appearance&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;non&quot;}]},{&quot;then_field&quot;:&quot;show-whitened&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-whitened&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]},{&quot;then_field&quot;:&quot;show-whitened-satisfied&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-whitened-satisfied&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;non&quot;}]},{&quot;then_field&quot;:&quot;show-something-else-discuss&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dental-fr-something-else-discuss&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;oui&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;,&quot;notice_dismissed_rollback-cf7-5.9.2&quot;:true}}\" \/><input type=\"hidden\" name=\"redirect_nonce\" value=\"7b7bde6c7a\" \/><input type=\"hidden\" name=\"wpcf7cfpdf_hidden_name\" value=\"qd-dental-fr-name\" \/><input type=\"hidden\" name=\"wpcf7cfpdf_hidden_reference\" value=\"6cd45d77\" \/><input type=\"hidden\" name=\"wpcf7cfpdf_hidden_date\" value=\"6June2026\" \/>\n<\/fieldset>\n<div class=\"sg-container\">\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>Patient <span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-name\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-6\">\n\t\t\t<p><label>\u00c2ge<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"dental-fr-age\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<h3>RAISON DE LA VISITE ET ANT\u00c9C\u00c9DENTS\n\t\t\t<\/h3>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>1. Que pouvons-nous faire pour vous ? (Exemple : 'V\u00e9rification et nettoyage', 'Je veux que mes dents soient belles', 'J'ai du mal \u00e0 mastiquer'...) <span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-reason\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-reason\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>2. \u00c0 quand remonte votre derni\u00e8re visite chez le dentiste pour un examen vraiment complet, d\u00e9taill\u00e9 et pr\u00e9cis ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-last-visit\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-last-visit\"><\/textarea><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>3. Vous souvenez-vous du nom de votre dentiste pr\u00e9c\u00e9dent ? (Nous ne contacterons PAS votre ancien dentiste. Si vous ne le savez pas, veuillez laisser le champ vide)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-name-previous-dentist\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-name-previous-dentist\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>4. Lors de votre dernier examen, y avait-il des travaux qui n'\u00e9taient pas termin\u00e9s ou des choses qu'il restait \u00e0 \u00ab surveiller \u00bb ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-uncompleted-work\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-uncompleted-work\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>5. \u00c0 quelle fr\u00e9quence passez-vous habituellement votre examen dentaire ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-usually-dental-exam\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-usually-dental-exam\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>6. Y a-t-il une raison particuli\u00e8re pour laquelle vous changez de dentiste ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-reason-changing-dentist\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-reason-changing-dentist\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>7. Sur une \u00e9chelle de 0 \u00e0 10, quel est votre niveau de peur ou d'anxi\u00e9t\u00e9 face \u00e0 la dentisterie ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-level-fear\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"dental-fr-level-fear\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>8. Y a-t-il quelque chose en particulier qui vous inqui\u00e8te ou vous d\u00e9range chez le dentiste ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-worries-bother\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-worries-bother\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<h3>LES DENTS\n\t\t\t<\/h3>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>9. Avez-vous des dents sensibles \u00e0 : <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-sensitive-to\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dental-fr-sensitive-to[]\" value=\"Chaud\" \/><span class=\"wpcf7-list-item-label\">Chaud<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"dental-fr-sensitive-to[]\" value=\"Froid\" \/><span class=\"wpcf7-list-item-label\">Froid<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"dental-fr-sensitive-to[]\" value=\"Sucr\u00e9\" \/><span class=\"wpcf7-list-item-label\">Sucr\u00e9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"dental-fr-sensitive-to[]\" value=\"Acides\" \/><span class=\"wpcf7-list-item-label\">Acides<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"dental-fr-sensitive-to[]\" value=\"Pression\" \/><span class=\"wpcf7-list-item-label\">Pression<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"dental-fr-sensitive-to[]\" value=\"Mastication\" \/><span class=\"wpcf7-list-item-label\">Mastication<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dental-fr-sensitive-to[]\" value=\"Aucun\" \/><span class=\"wpcf7-list-item-label\">Aucun<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>10. La nourriture reste-t-elle coinc\u00e9e entre les dents ou la soie dentaire brise-t-elle ou s'accroche-t-elle \u00e0 certains endroits ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-food-stuck\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-food-stuck\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-food-stuck\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-food-stuck\" data-orig_data_id=\"show-food-stuck\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-food-stuck-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-food-stuck-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>11. Avez-vous des obturations qui sont tomb\u00e9es ou qui se sont fissur\u00e9es ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-filling-fallen\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-filling-fallen\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-filling-fallen\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-filling-fallen\" data-orig_data_id=\"show-filling-fallen\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-filling-fallen-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-filling-fallen-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<h3>GENCIVE\n\t\t\t<\/h3>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>12. Vos gencives saignent (m\u00eame un peu) ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-gum-bleed\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-gum-bleed\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-gum-bleed\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-gum-bleed\" data-orig_data_id=\"show-gum-bleed\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Quand?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-gum-bleed-when\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dental-fr-gum-bleed-when[]\" value=\"au brossage\" \/><span class=\"wpcf7-list-item-label\">au brossage<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dental-fr-gum-bleed-when[]\" value=\"en utilisant la soie dentaire\" \/><span class=\"wpcf7-list-item-label\">en utilisant la soie dentaire<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>13. \u00c0 quelle fr\u00e9quence en moyenne vous brossez-vous les dents et passez-vous la soie dentaire ?<\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Brossage <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-often-brush-brushing\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-often-brush-brushing\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Soie dentaire<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-often-brush-flossing\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-often-brush-flossing\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>Rince bouche<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-often-brush-mouthwash\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-often-brush-mouthwash\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>D'autres \u00e9quipements ? (\"hydropulseur, brossettes interdentaires\")<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-often-brush-adjuvants\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-often-brush-adjuvants\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>14. \u00c0 votre connaissance, y a-t-il un membre de votre famille qui a eu une maladie des gencives ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-family-disease\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-family-disease\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-family-disease\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-family-disease\" data-orig_data_id=\"show-family-disease\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-family-disease-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-family-disease-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>15. \u00cates-vous confiant de votre haleine ou avez-vous parfois un mauvais go\u00fbt dans la bouche ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-confident-breath\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-confident-breath\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-confident-breath\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-confident-breath\" data-orig_data_id=\"show-confident-breath\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-confident-breath-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-confident-breath-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<h3>FONCTION DES DENTS\n\t\t\t<\/h3>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>16. Vous emp\u00eachez-vous de m\u00e2cher des aliments durs ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-restrain-chewing\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-restrain-chewing\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-restrain-chewing\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-restrain-chewing\" data-orig_data_id=\"show-restrain-chewing\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-restrain-chewing-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-restrain-chewing-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>17. Avez-vous l'impression de grincer ou de serrer les dents ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-feel-grind\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-feel-grind\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-feel-grind\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-feel-grind\" data-orig_data_id=\"show-feel-grind\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-feel-grind-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-feel-grind-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>18. Avez-vous l'impression qu'il ne ferme pas \u00e9gal ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-feel-not-equal\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-feel-not-equal\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-feel-not-equal\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-feel-not-equal\" data-orig_data_id=\"show-feel-not-equal\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-feel-not-equal-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-feel-not-equal-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>19. Vos dents sont us\u00e9es, fissur\u00e9es ou transparentes ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-teeth-worn-out\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-teeth-worn-out\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-teeth-worn-out\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-teeth-worn-out\" data-orig_data_id=\"show-teeth-worn-out\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-teeth-worn-out-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-teeth-worn-out-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>20. Est-ce que votre m\u00e2choire se bloque, craque ou fait du bruit lorsque vous m\u00e2chez ou b\u00e2illez ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-jaw-locks\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-jaw-locks\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-jaw-locks\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-jaw-locks\" data-orig_data_id=\"show-jaw-locks\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-jaw-locks-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-jaw-locks-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>21. Vos dents ou votre m\u00e2choire sont sensibles le matin ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-sensitive-morning\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-sensitive-morning\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-sensitive-morning\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-sensitive-morning\" data-orig_data_id=\"show-sensitive-morning\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-sensitive-morning-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-sensitive-morning-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<h3>ESTH\u00c9TIQUE\n\t\t\t<\/h3>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>22. Avez-vous eu un traitement orthodontique (broches) et quelles sont\/\u00e9taient les r\u00e9tentions ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-orthodontic-treatment\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-orthodontic-treatment\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-orthodontic-treatment\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-orthodontic-treatment\" data-orig_data_id=\"show-orthodontic-treatment\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-orthodontic-treatment-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-orthodontic-treatment-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>23. \u00cates-vous satisfait de l'aspect esth\u00e9tique de vos dents ou souhaitez-vous am\u00e9liorer quelque chose ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-satisfied-appearance\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-satisfied-appearance\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-satisfied-appearance\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-satisfied-appearance\" data-orig_data_id=\"show-satisfied-appearance\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-satisfied-appearance-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-satisfied-appearance-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>24. Vos dents ont-elles \u00e9t\u00e9 blanchies ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-whitened\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-whitened\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-whitened\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-whitened\" data-orig_data_id=\"show-whitened\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Quand?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-whitened-when\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-whitened-when\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Comment?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-whitened-how\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dental-fr-whitened-how\" \/><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>25. \u00cates-vous satisfait du r\u00e9sultat?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-whitened-satisfied\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-whitened-satisfied\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-whitened-satisfied\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div data-id=\"show-whitened-satisfied\" data-orig_data_id=\"show-whitened-satisfied\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-whitened-satisfied-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-whitened-satisfied-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<h3>AUTRE\n\t\t\t<\/h3>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><label>26. Y a-t-il autre chose dont vous voudriez discuter ?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-something-else-discuss\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dental-fr-something-else-discuss\" value=\"oui\" \/><span class=\"wpcf7-list-item-label\">oui<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dental-fr-something-else-discuss\" value=\"non\" \/><span class=\"wpcf7-list-item-label\">non<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"show-something-else-discuss\" data-orig_data_id=\"show-something-else-discuss\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"sg-row\">\n\t\t\t<div class=\"sg-col-12\">\n\t\t\t\t<p><label>Expliquez:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dental-fr-something-else-discuss-reason\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dental-fr-something-else-discuss-reason\"><\/textarea><\/span><\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"sg-row\">\n\t\t<div class=\"sg-col-12\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output fusion-alert-capitalize awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-size:1px;--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n<\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:26px;--awb-padding-bottom:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1320.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:0%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div ><a class=\"fusion-button button-flat button-xlarge button-custom fusion-button-default button-2 fusion-button-default-span fusion-button-default-type\" style=\"--button_accent_color:#656a70;--button_accent_hover_color:#6b6b6b;--button_border_hover_color:#ffffff;--button_gradient_top_color:rgba(0,0,0,0);--button_gradient_bottom_color:rgba(0,0,0,0);--button_gradient_top_color_hover:rgba(40,45,51,0.1);--button_gradient_bottom_color_hover:rgba(40,45,51,0.1);\" target=\"_self\" href=\"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/forms\/\"><i class=\"fa-arrow-left fas awb-button__icon awb-button__icon--default button-icon-left\" aria-hidden=\"true\"><\/i><span class=\"fusion-button-text awb-button__text awb-button__text--default\">RETOURNER AU FORMULAIRES<\/span><\/a><\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":3786,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-3790","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3790","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/comments?post=3790"}],"version-history":[{"count":8,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3790\/revisions"}],"predecessor-version":[{"id":3956,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3790\/revisions\/3956"}],"up":[{"embeddable":true,"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/pages\/3786"}],"wp:attachment":[{"href":"https:\/\/vjwq067yt6d.c.updraftclone.com\/fr\/wp-json\/wp\/v2\/media?parent=3790"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}