Form

<form action="/en/referring-doctors/#wpcf7-f156-p298-o1" method="post" class="wpcf7-form" enctype="multipart/form-data" novalidate="novalidate">
<div style="display: none;">
<input type="hidden" name="_wpcf7" value="156">
<input type="hidden" name="_wpcf7_version" value="5.0.3">
<input type="hidden" name="_wpcf7_locale" value="en_US">
<input type="hidden" name="_wpcf7_unit_tag" value="wpcf7-f156-p298-o1">
<input type="hidden" name="_wpcf7_container_post" value="298">
</div>
<div class="row">
<div class="form-group col-md-6">
<p>Les champs marqués d’un astérisque (<span class="blue">*</span>) sont obligatoires.</p>
<p><i>Fields marked with an asterisk  (<span class="blue">*</span>) are required.</i></p>
</div>
<div class="form-group col-md-6">
<span class="wpcf7-form-control-wrap DateDate"><input type="text" name="DateDate" value="" size="40" class="wpcf7-form-control wpcf7-date wpcf7-validates-as-required w3-input w3-border hasDatepicker" aria-required="true" placeholder="Date / Date *" id="dp1550486044966"> </span>
</div>
<div class="form-group col-md-12">
<hr>
</div>
<p><!-- Dr --></p>
<div class="col-md-6">
<p class="font-18 text-uppercase">Dentiste référent / <i>Referring dentist</i></p>
<div class="form-group">
<span class="wpcf7-form-control-wrap referringDr"><input type="text" name="referringDr" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Dr. *"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap referringTlphonePhone"><input type="tel" name="referringTlphonePhone" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Téléphone / Phone *"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap referringCourrielEmail"><input type="email" name="referringCourrielEmail" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email w3-input w3-border" aria-invalid="false" placeholder="Courriel / Email"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap referringAdresseAddress"><input type="text" name="referringAdresseAddress" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Adresse / Address *"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap referringProvinces"><select name="referringProvinces" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required w3-select w3-border" aria-required="true" aria-invalid="false"><option value="Quebec">Quebec</option><option value="Ontario">Ontario</option><option value="British Columbia">British Columbia</option><option value="Alberta">Alberta</option><option value="Manitoba">Manitoba</option><option value="Saskatchewan">Saskatchewan</option><option value="Nova Scotia">Nova Scotia</option><option value="New Brunswick">New Brunswick</option><option value="Newfoundland and Labrador">Newfoundland and Labrador</option><option value="Prince Edward Island">Prince Edward Island</option><option value="Northwest Territories">Northwest Territories</option><option value="Yukon">Yukon</option><option value="Nunavut">Nunavut</option></select></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap referringVilleCity"><input type="text" name="referringVilleCity" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Ville / City *"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap referringCodepostaleZipCode"><input type="text" name="referringCodepostaleZipCode" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Code postal / Postal code *"></span>
</div>
</div>
<p><!-- Patient --></p>
<div class="col-md-6">
<p class="font-18 text-uppercase">patient</p>
<div class="form-group">
<span class="wpcf7-form-control-wrap patientgender"><span class="wpcf7-form-control wpcf7-radio w3-radio"><span class="wpcf7-list-item first"><input type="radio" name="patientgender" value="M. / Mr." checked="checked"><span class="wpcf7-list-item-label">M. / Mr.</span></span><span class="wpcf7-list-item last"><input type="radio" name="patientgender" value="Mme / Ms."><span class="wpcf7-list-item-label">Mme / Ms.</span></span></span></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap patientPrnomFirstName"><input type="text" name="patientPrnomFirstName" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Prénom / First Name *"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap patientNomLastName"><input type="text" name="patientNomLastName" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Nom / Last Name *"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap patientTlphone1Phone1"><input type="text" name="patientTlphone1Phone1" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required w3-input w3-border" aria-required="true" aria-invalid="false" placeholder="Téléphone 1 / Phone 1 *"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap patientTlphone2Phone2"><input type="text" name="patientTlphone2Phone2" value="" size="40" class="wpcf7-form-control wpcf7-text w3-input w3-border" aria-invalid="false" placeholder="Téléphone 2 / Phone 2"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap patientCourrielEmail"><input type="email" name="patientCourrielEmail" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email w3-input w3-border" aria-invalid="false" placeholder="Courriel / Email"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap patientDatedenaissanceDateofbirth"><input type="text" name="patientDatedenaissanceDateofbirth" value="" size="40" class="wpcf7-form-control wpcf7-date wpcf7-validates-as-required w3-input w3-border hasDatepicker" aria-required="true" placeholder="Date de naissance / Date of birth (DD-MM-YYYY) *" id="dp1550486044967"> </span>
</div>
</div>
<div class="form-group col-md-12">
<hr>
</div>
<div class="col-md-6">
<p class="font-18 text-uppercase">Dent(s) / <i>Tooth (teeth)</i>   </p>
<div class="form-group">
<span class="wpcf7-form-control-wrap DENTSTOOTHTEETH"><input type="text" name="DENTSTOOTHTEETH" value="" size="40" class="wpcf7-form-control wpcf7-text w3-input w3-border" aria-invalid="false"></span>
</div>
<div class="form-group">
<span class="wpcf7-form-control-wrap treatments"><select name="treatments" class="wpcf7-form-control wpcf7-select wpcf7-validates-as-required w3-select w3-border" aria-required="true" aria-invalid="false"><option value="Traitement d'urgence / Emergency treatment">Traitement d'urgence / Emergency treatment</option><option value="Scan 3D/ 3D Scan">Scan 3D/ 3D Scan</option><option value="Consultation diagnostique / Diagnosis">Consultation diagnostique / Diagnosis</option><option value="Traitement de canal / Root canal treatment">Traitement de canal / Root canal treatment</option><option value="Retraitement / Retreatment">Retraitement / Retreatment</option><option value="Chirurgie apicale / Apical surgery">Chirurgie apicale / Apical surgery</option><option value="Apexification ou regénération / Apexification or regeneration">Apexification ou regénération / Apexification or regeneration</option><option value="Réimplantation intentionnelle / Intentional replantation">Réimplantation intentionnelle / Intentional replantation</option><option value="Blanchiment interne / Internal bleaching">Blanchiment interne / Internal bleaching</option><option value="Gestion des traumas/ Trauma management">Gestion des traumas/ Trauma management</option><option value="Résorption interne ou externe/ Internal or External Resorption">Résorption interne ou externe/ Internal or External Resorption</option></select></span>
</div>
</div>
<div class="col-md-6">
<p class="font-18 text-uppercase">Restaurer avec / <i>Restore with</i>  </p>
<div class="form-group">
<span class="wpcf7-form-control-wrap RESTAURERAVECRESTOREWITH"><span class="wpcf7-form-control wpcf7-radio w3-radio fullo"><span class="wpcf7-list-item first"><input type="radio" name="RESTAURERAVECRESTOREWITH" value="Boulette de cotton et restauration temporaire / Cotton pellet &amp; temporary restoration" checked="checked"><span class="wpcf7-list-item-label">Boulette de cotton et restauration temporaire / Cotton pellet &amp; temporary restoration</span></span><span class="wpcf7-list-item last"><input type="radio" name="RESTAURERAVECRESTOREWITH" value="Restauration finale en composite / Final composite"><span class="wpcf7-list-item-label">Restauration finale en composite / Final composite</span></span></span></span>
</div>
<p class="font-18 text-uppercase">Espace pivot / <i>Post space</i></p>
<div class="form-group">
<span class="wpcf7-form-control-wrap ESPACEPIVOTPOSTSPACE"><span class="wpcf7-form-control wpcf7-radio w3-radio"><span class="wpcf7-list-item first"><input type="radio" name="ESPACEPIVOTPOSTSPACE" value="Oui / Yes" checked="checked"><span class="wpcf7-list-item-label">Oui / Yes</span></span><span class="wpcf7-list-item last"><input type="radio" name="ESPACEPIVOTPOSTSPACE" value="Non / No"><span class="wpcf7-list-item-label">Non / No</span></span></span></span>
</div>
</div>
<div class="form-group col-md-12">
<hr>
</div>
<div class="col-md-6">
<p class="font-18 text-uppercase">Radiographie(s) / <i>Radiograph(s)</i></p>
<div class="form-group">
<span class="wpcf7-form-control-wrap RADIOGRAPHIESRADIOGRAPHS"><span class="wpcf7-form-control wpcf7-radio w3-radio fullo"><span class="wpcf7-list-item first"><input type="radio" name="RADIOGRAPHIESRADIOGRAPHS" value="Par la poste / By mail" checked="checked"><span class="wpcf7-list-item-label">Par la poste / By mail</span></span><span class="wpcf7-list-item last"><input type="radio" name="RADIOGRAPHIESRADIOGRAPHS" value="Par courriel / By email"><span class="wpcf7-list-item-label">Par courriel / By email</span></span></span></span>
</div>
<div class="form-group">
<label>Joindre vos radios / Attach you Xrays (.pdf .jpg)<br>( plusieurs fichiers autorisés / multiple files allowed)</label><br>
<span class="wpcf7-form-control-wrap attachments"><input type="file" name="attachments[]" size="40" class="wpcf7-form-control wpcf7-multifile w3-input w3-border" multiple="multiple" aria-invalid="false"></span>
</div>
</div>
<div class="col-md-6">
<p class="font-18 text-uppercase">Envoyer le rapport / <i>Send report</i></p>
<div class="form-group">
<span class="wpcf7-form-control-wrap ENVOYERLERAPPORTSENDREPORT"><span class="wpcf7-form-control wpcf7-radio w3-radio fullo"><span class="wpcf7-list-item first"><input type="radio" name="ENVOYERLERAPPORTSENDREPORT" value="Par la poste / By mail" checked="checked"><span class="wpcf7-list-item-label">Par la poste / By mail</span></span><span class="wpcf7-list-item last"><input type="radio" name="ENVOYERLERAPPORTSENDREPORT" value="Par courriel / By email"><span class="wpcf7-list-item-label">Par courriel / By email</span></span></span></span>
</div>
</div>
<div class="form-group col-md-12">
<hr>
</div>
<div class="form-group col-md-12">
<label class="text-uppercase">Remarques / <i>Comments</i></label><br>
<span class="wpcf7-form-control-wrap REMARQUESCOMMENTS"><textarea name="REMARQUESCOMMENTS" cols="40" rows="10" class="wpcf7-form-control wpcf7-textarea w3-text w3-border" aria-invalid="false"></textarea></span>
</div>
<div class="form-group col-md-12 text-right">
<input type="submit" class="btn" value="soumettre">
</div>
</div>
<div class="wpcf7-response-output wpcf7-display-none"></div></form>