{"id":112,"date":"2018-02-08T11:46:45","date_gmt":"2018-02-08T16:46:45","guid":{"rendered":"http:\/\/www.uqac.ca\/cupht\/?page_id=112"},"modified":"2023-03-24T15:17:32","modified_gmt":"2023-03-24T19:17:32","slug":"formulaire-de-reference","status":"publish","type":"page","link":"https:\/\/www.uqac.ca\/cupht\/formidable-id6\/formulaire-de-reference\/","title":{"rendered":"FORMULAIRE DE R\u00c9F\u00c9RENCE EN LIGNE"},"content":{"rendered":"<p>La personne r\u00e9f\u00e9r\u00e9e peut elle-m\u00eame compl\u00e9ter le formulaire de r\u00e9f\u00e9rence, <u>tout en s\u2019assurant qu\u2019une r\u00e9f\u00e9rence en physioth\u00e9rapie de son professionnel de la sant\u00e9 <\/u>soit achemin\u00e9e \u00e0 la clinique pour le traitement de sa demande de services en physioth\u00e9rapie.<\/p>\n<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_6_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_ajax_submit  frm_pro_form \" id=\"form_hhpqs\" >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_hidden\">Formulaire de r\u00e9f\u00e9rence<\/legend>\r\n<h3 class=\"frm_form_title\">Formulaire de r\u00e9f\u00e9rence<\/h3>\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"6\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_6\" id=\"frm_hide_fields_6\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"hhpqs\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_6\" name=\"frm_submit_entry_6\" value=\"e75271241c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/cupht\/wp-json\/wp\/v2\/pages\/112\" \/><div id=\"frm_field_67_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top\">SECTION A<\/h3>\r\n<div id=\"frm_desc_field_6pqyn\" class=\"frm_description frm_section_spacing\">IDENTIFICATION DE L'USAGER<\/div>\r\n\r\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_faqg0\" class=\"frm_primary_label\">NOM\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_faqg0\" name=\"item_meta[69]\" value=\"\"  data-sectionid=\"67\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"NOM est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_pn98k\" class=\"frm_primary_label\">PR\u00c9NOM\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_pn98k\" name=\"item_meta[70]\" value=\"\"  data-sectionid=\"67\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"PR\u00c9NOM est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_bdany\" class=\"frm_primary_label\">DATE DE NAISSANCE\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bdany\" name=\"item_meta[72]\" value=\"\"  data-sectionid=\"67\"  maxlength=\"10\" data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"DATE DE NAISSANCE est non valide\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_101_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_alignright\">\r\n    <label for=\"field_b6kej\" class=\"frm_primary_label\">\u00c2GE\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_b6kej\" name=\"item_meta[101]\" value=\"\" data-sectionid=\"67\"  style=\"width:50px\" data-invmsg=\"\u00c2GE est non valide\" class=\"auto_width\" aria-invalid=\"false\"   min=\"0\" max=\"120\" step=\"any\" \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_128_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_other_container\">\r\n    <label for=\"field_nu068\" class=\"frm_primary_label\">SEXE\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[128]\" id=\"field_nu068\"  data-sectionid=\"67\"  data-frmval=\"S\u00e9lectionner\" data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"SEXE est non valide\" aria-invalid=\"false\"  >\n\t\t<option  value=\"S\u00e9lectionner\" selected='selected'>S\u00e9lectionner<\/option><option  value=\"F\u00e9minin\">F\u00e9minin<\/option><option  value=\"Masculin\">Masculin<\/option><option  value=\"Autre\" class=\"frm_other_trigger\">Autre<\/option>\t<\/select>\n\t<label for=\"field_nu068-otext\" class=\"frm_screen_reader frm_hidden\">SEXE<\/label><input type=\"text\" id=\"field_nu068-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][128]\" value=\"\" \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_half\">\r\n    <label for=\"field_jz8r2\" class=\"frm_primary_label\">NUM\u00c9RO RAMQ\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_jz8r2\" name=\"item_meta[76]\" value=\"\"  data-sectionid=\"67\"  data-invmsg=\"NUM\u00c9RO RAMQ est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_100_container\" class=\"frm_form_field form-field  frm_top_container frm_half frm_alignright\">\r\n    <label for=\"field_bozmo\" class=\"frm_primary_label\">EXPIRATION\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_bozmo\" name=\"item_meta[100]\" value=\"\"  data-sectionid=\"67\"  style=\"width:200px\" maxlength=\"10\" data-invmsg=\"EXPIRATION est non valide\" class=\"frm_date auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_sndfq\" class=\"frm_primary_label\">ADRESSE POSTALE COMPL\u00c8TE AVEC CODE POSTAL\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_sndfq\" name=\"item_meta[77]\" value=\"\"  data-sectionid=\"67\"  data-invmsg=\"ADRESSE POSTALE COMPL\u00c8TE AVEC CODE POSTAL est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_b9ave\" class=\"frm_primary_label\">NO DE T\u00c9L\u00c9PHONE #1\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[79]\" id=\"field_b9ave\"  data-sectionid=\"67\"  data-frmval=\"S\u00e9lectionner\" data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"NO DE T\u00c9L\u00c9PHONE #1 est non valide\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  value=\"S\u00e9lectionner\" selected='selected'>S\u00e9lectionner<\/option><option  value=\"DOMICILE\">DOMICILE<\/option><option  value=\"CELLULAIRE\">CELLULAIRE<\/option><option  value=\"TRAVAIL\">TRAVAIL<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_102_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_uiify\" class=\"frm_primary_label\">Num\u00e9ro de t\u00e9l\u00e9phone\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_uiify\" name=\"item_meta[102]\" value=\"\"  data-sectionid=\"67\"  data-frmmask=\"(999)999-9999\" style=\"width:300px\" maxlength=\"13\" data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"Num\u00e9ro de t\u00e9l\u00e9phone est non valide\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"\\(\\d\\d\\d\\)\\d\\d\\d-\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_106_container\" class=\"frm_form_field form-field  frm_top_container frm_inline\">\r\n    <label for=\"field_vbuu\" class=\"frm_primary_label\">Num\u00e9ro de poste\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_vbuu\" name=\"item_meta[106]\" value=\"\" data-sectionid=\"67\"  style=\"width:100px\" data-invmsg=\"Num\u00e9ro de poste est non valide\" class=\"auto_width\" aria-invalid=\"false\"   min=\"0\" max=\"9999999\" step=\"any\" \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_half\">\r\n    <label for=\"field_os0kc\" class=\"frm_primary_label\">NO DE T\u00c9L\u00c9PHONE #2\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[80]\" id=\"field_os0kc\"  data-sectionid=\"67\"  data-frmval=\"S\u00e9lectionner\" data-invmsg=\"NO DE T\u00c9L\u00c9PHONE #2 est non valide\" class=\"auto_width\" aria-invalid=\"false\"  >\n\t\t<option  value=\"S\u00e9lectionner\" selected='selected'>S\u00e9lectionner<\/option><option  value=\"DOMICILE\">DOMICILE<\/option><option  value=\"CELLULAIRE\">CELLULAIRE<\/option><option  value=\"TRAVAIL\">TRAVAIL<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_103_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_half\">\r\n    <label for=\"field_bbk0u\" class=\"frm_primary_label\">Num\u00e9ro de t\u00e9l\u00e9phone\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_bbk0u\" name=\"item_meta[103]\" value=\"\"  data-sectionid=\"67\"  data-frmmask=\"(999)999-9999\" style=\"width:300px\" maxlength=\"13\" data-invmsg=\"Num\u00e9ro de t\u00e9l\u00e9phone est non valide\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"\\(\\d\\d\\d\\)\\d\\d\\d-\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_107_container\" class=\"frm_form_field form-field  frm_top_container frm_inline\">\r\n    <label for=\"field_40ert\" class=\"frm_primary_label\">Num\u00e9ro de poste\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_40ert\" name=\"item_meta[107]\" value=\"\" data-sectionid=\"67\"  style=\"width:100px\" data-invmsg=\"Num\u00e9ro de poste est non valide\" class=\"auto_width\" aria-invalid=\"false\"   min=\"0\" max=\"9999999\" step=\"any\" \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_126_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_56y4p\" class=\"frm_primary_label\">Courriel\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_56y4p\" name=\"item_meta[126]\" value=\"\"  data-sectionid=\"67\"  data-invmsg=\"Courriel est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top\">SECTION B<\/h3>\r\n<div id=\"frm_desc_field_1yjfy\" class=\"frm_description frm_section_spacing\">DIAGNOSTIC DE R\u00c9F\u00c9RENCE<\/div>\r\n\r\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_orewc\" class=\"frm_primary_label\">DIAGNOSTIC\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_orewc\" name=\"item_meta[86]\" value=\"\"  data-sectionid=\"84\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"DIAGNOSTIC est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_88_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_wve5z\" class=\"frm_primary_label\">MOTIF DE R\u00c9F\u00c9RENCE\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[88]\" id=\"field_wve5z\"  data-sectionid=\"84\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"MOTIF DE R\u00c9F\u00c9RENCE est non valide\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_114_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">CONTRE-INDICATIONS OU RESTRICTIONS \u00c0 L'ENTRA\u00ceNEMENT OU AUX EXERCICES CARDIORESPIRATOIRES ET VASCULAIRES?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_114-84-0\">\t\t\t<label  for=\"field_gmom7-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[114]\" id=\"field_gmom7-0\" value=\"Oui\"\n\t\t   data-sectionid=\"84\"  data-invmsg=\"CONTRE-INDICATIONS OU RESTRICTIONS \u00c0 L&#039;ENTRA\u00ceNEMENT OU AUX EXERCICES CARDIORESPIRATOIRES ET VASCULAIRES? est non valide\" aria-invalid=\"false\"  \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_114-84-1\">\t\t\t<label  for=\"field_gmom7-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[114]\" id=\"field_gmom7-1\" value=\"Non\"\n\t\t   data-sectionid=\"84\"  data-invmsg=\"CONTRE-INDICATIONS OU RESTRICTIONS \u00c0 L&#039;ENTRA\u00ceNEMENT OU AUX EXERCICES CARDIORESPIRATOIRES ET VASCULAIRES? est non valide\" aria-invalid=\"false\"  \/> Non<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_115_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_mq5xd\" class=\"frm_primary_label\">SI OUI, PR\u00c9CISEZ:\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[115]\" id=\"field_mq5xd\" rows=\"5\"  data-sectionid=\"84\"  data-invmsg=\"SI OUI, PR\u00c9CISEZ: est non valide\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_116_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label  class=\"frm_primary_label\">CONTRE-INDICATIONS OU RESTRICTIONS \u00c0 L'ENTRA\u00ceNEMENT OU AUX EXERCICES DE RENFORCEMENT MUSCULAIRE ET DE MOBILIT\u00c9?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_116-84-0\">\t\t\t<label  for=\"field_ucj63-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[116]\" id=\"field_ucj63-0\" value=\"Oui\"\n\t\t   data-sectionid=\"84\"  data-invmsg=\"CONTRE-INDICATIONS OU RESTRICTIONS \u00c0 L&#039;ENTRA\u00ceNEMENT OU AUX EXERCICES DE RENFORCEMENT MUSCULAIRE ET DE MOBILIT\u00c9? est non valide\" aria-invalid=\"false\"  \/> Oui<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_116-84-1\">\t\t\t<label  for=\"field_ucj63-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[116]\" id=\"field_ucj63-1\" value=\"Non\"\n\t\t   data-sectionid=\"84\"  data-invmsg=\"CONTRE-INDICATIONS OU RESTRICTIONS \u00c0 L&#039;ENTRA\u00ceNEMENT OU AUX EXERCICES DE RENFORCEMENT MUSCULAIRE ET DE MOBILIT\u00c9? est non valide\" aria-invalid=\"false\"  \/> Non<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_118_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_xpm9d\" class=\"frm_primary_label\">SI OUI, PR\u00c9CISEZ\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[118]\" id=\"field_xpm9d\" rows=\"5\"  data-sectionid=\"84\"  data-invmsg=\"SI OUI, PR\u00c9CISEZ est non valide\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_5l4q3\" class=\"frm_primary_label\">M\u00c9DICATION\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[91]\" id=\"field_5l4q3\"  data-sectionid=\"84\"  data-invmsg=\"M\u00c9DICATION est non valide\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_92_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_p0njl\" class=\"frm_primary_label\">EXAMENS PERTINENTS\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[92]\" id=\"field_p0njl\"  data-sectionid=\"84\"  data-invmsg=\"EXAMENS PERTINENTS est non valide\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_123_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_6a5ai\" class=\"frm_primary_label\">Type de client\u00e8le de la CUpht\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"url\" id=\"field_6a5ai\" name=\"item_meta[123]\" value=\"https:\/\/www-temp.uqac.ca\/cupht\/accueil\/clienteles\/\"  data-sectionid=\"84\"  data-frmval=\"https:\/\/www-temp.uqac.ca\/cupht\/accueil\/clienteles\/\" data-invmsg=\"Site Web\/URL est non valide\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_93_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top\">SECTION C<\/h3>\r\n<div id=\"frm_desc_field_xxxa8\" class=\"frm_description frm_section_spacing\">IDENTIFICATION DU R\u00c9F\u00c9RENT (M\u00c9DECIN OU PROFESSIONNEL DE LA SANT\u00c9)<\/div>\r\n\r\n<div id=\"frm_field_95_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_r0792\" class=\"frm_primary_label\">NOM DU R\u00c9F\u00c9RENT ET PROFESSION\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_r0792\" name=\"item_meta[95]\" value=\"\"  data-sectionid=\"93\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"NOM DU R\u00c9F\u00c9RENT ET PROFESSION est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_96_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_2em1c\" class=\"frm_primary_label\">\u00c9TABLISSEMENT\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_2em1c\" name=\"item_meta[96]\" value=\"\"  data-sectionid=\"93\"  data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"\u00c9TABLISSEMENT est non valide\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_104_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first\">\r\n    <label for=\"field_34ijc\" class=\"frm_primary_label\">NO DE T\u00c9L\u00c9PHONE\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_34ijc\" name=\"item_meta[104]\" value=\"\"  data-sectionid=\"93\"  data-frmmask=\"(999)999-9999\" style=\"width:300px\" maxlength=\"13\" data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"NUM\u00c9RO DE T\u00c9L\u00c9PHONE est non valide\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"\\(\\d\\d\\d\\)\\d\\d\\d-\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_108_container\" class=\"frm_form_field form-field  frm_top_container frm_inline\">\r\n    <label for=\"field_ifwgy\" class=\"frm_primary_label\">Num\u00e9ro de poste\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_ifwgy\" name=\"item_meta[108]\" value=\"\" data-sectionid=\"93\"  style=\"width:100px\" data-invmsg=\"Num\u00e9ro de poste est non valide\" class=\"auto_width\" aria-invalid=\"false\"   min=\"0\" max=\"9999999\" step=\"any\" \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_98_container\" class=\"frm_form_field form-field  frm_top_container frm_first frm_half\">\r\n    <label for=\"field_yu1fh\" class=\"frm_primary_label\">COURRIEL\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_yu1fh\" name=\"item_meta[98]\" value=\"\"  data-sectionid=\"93\"  data-invmsg=\"COURRIEL est non valide\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_99_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half frm_alignright\">\r\n    <label for=\"field_3ksd2\" class=\"frm_primary_label\">DATE DE R\u00c9F\u00c9RENCE\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_3ksd2\" name=\"item_meta[99]\" value=\"\"  data-sectionid=\"93\"  style=\"width:200px\" maxlength=\"10\" data-reqmsg=\"Ce champ ne peut pas \u00eatre vide\" aria-required=\"true\" data-invmsg=\"DATE DE R\u00c9F\u00c9RENCE est non valide\" class=\"frm_date auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_111_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top\">SECTION D<\/h3>\r\n<div id=\"frm_desc_field_92q81\" class=\"frm_description frm_section_spacing\">IDENTIFICATION DE LA PERSONNE COMPL\u00c9TANT LE FORMULAIRE DE R\u00c9F\u00c9RENCE<\/div>\r\n\r\n<div id=\"frm_field_113_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio frm_other_container\">\r\n    <label  class=\"frm_primary_label\">VEUILLEZ SVP INDIQUER QUI A COMPL\u00c9T\u00c9 CE FORMULAIRE :\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_113-111-0\">\t\t\t<label  for=\"field_mmt85-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[113]\" id=\"field_mmt85-0\" value=\"M\u00e9decin\"\n\t\t   data-sectionid=\"111\"  data-invmsg=\"VEUILLEZ SVP INDIQUER QUI A COMPL\u00c9T\u00c9 CE FORMULAIRE : est non valide\" aria-invalid=\"false\"  \/> M\u00e9decin<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_113-111-1\">\t\t\t<label  for=\"field_mmt85-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[113]\" id=\"field_mmt85-1\" value=\"Professionnel de la sant\u00e9\"\n\t\t   data-sectionid=\"111\"  data-invmsg=\"VEUILLEZ SVP INDIQUER QUI A COMPL\u00c9T\u00c9 CE FORMULAIRE : est non valide\" aria-invalid=\"false\"  \/> Professionnel de la sant\u00e9<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_113-111-2\">\t\t\t<label  for=\"field_mmt85-2\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[113]\" id=\"field_mmt85-2\" value=\"Client lui-m\u00eame\"\n\t\t   data-sectionid=\"111\"  data-invmsg=\"VEUILLEZ SVP INDIQUER QUI A COMPL\u00c9T\u00c9 CE FORMULAIRE : est non valide\" aria-invalid=\"false\"  \/> Client lui-m\u00eame<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_113-111-other_3\">\t\t\t<label  for=\"field_mmt85-other_3\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[113]\" id=\"field_mmt85-other_3\" value=\"Autre\"\n\t\t   data-sectionid=\"111\"  data-invmsg=\"VEUILLEZ SVP INDIQUER QUI A COMPL\u00c9T\u00c9 CE FORMULAIRE : est non valide\" aria-invalid=\"false\"  \/> Autre<\/label><label for=\"field_mmt85-other_3-otext\" class=\"frm_screen_reader frm_hidden\">Autre<\/label><input type=\"text\" id=\"field_mmt85-other_3-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][113]\" value=\"\" \/><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_125_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_a7u3x\" class=\"frm_primary_label\">Remarques\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[125]\" id=\"field_a7u3x\" rows=\"3\"  data-sectionid=\"111\"  data-invmsg=\"Remarques est non valide\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_140_container\" class=\"frm_form_field form-field  frm_none_container\">\n\t<label for=\"g-recaptcha-response\" id=\"field_musoq_label\" class=\"frm_primary_label\">Captcha\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<div  id=\"field_musoq\" class=\"g-recaptcha\" data-sitekey=\"6Ldu-tQpAAAAAMWfhEn2vvLXBLWB9BabH8Ly5uea\" data-size=\"invisible\" data-theme=\"light\" data-callback=\"frmAfterRecaptcha\"><\/div>\n\t\n\t\n<\/div>\n<div id=\"frm_field_137_container\" class=\"frm_form_field form-field \">\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Envoyer<\/button>\r\n\r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_185_container\">\n\t\t\t<label for=\"field_qdunk\" >\n\t\t\t\tSi vous \u00eates un humain, ne remplissez pas ce champ.\t\t\t<\/label>\n\t\t\t<input  id=\"field_qdunk\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[185]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"fJieYr755MjTLes\/TkCJnXLpqH4a5Migj8w0tpB9bB4+Do3uOZoBgo9dpzJFGQik\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>La personne r\u00e9f\u00e9r\u00e9e peut elle-m\u00eame compl\u00e9ter le formulaire de r\u00e9f\u00e9rence, tout en s\u2019assurant qu\u2019une r\u00e9f\u00e9rence en physioth\u00e9rapie de son professionnel de la sant\u00e9 soit achemin\u00e9e \u00e0 la clinique pour le traitement de sa demande de services en physioth\u00e9rapie.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":43,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/pages\/112"}],"collection":[{"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/comments?post=112"}],"version-history":[{"count":12,"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/pages\/112\/revisions"}],"predecessor-version":[{"id":385,"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/pages\/112\/revisions\/385"}],"up":[{"embeddable":true,"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/pages\/43"}],"wp:attachment":[{"href":"https:\/\/www.uqac.ca\/cupht\/wp-json\/wp\/v2\/media?parent=112"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}