{"id":49489,"date":"2025-03-19T22:28:53","date_gmt":"2025-03-20T02:28:53","guid":{"rendered":"https:\/\/covid.securimed.ca\/?page_id=49489"},"modified":"2025-03-19T22:29:49","modified_gmt":"2025-03-20T02:29:49","slug":"consentement-hors-canada","status":"publish","type":"page","link":"https:\/\/covid.securimed.ca\/es\/consentement-hors-canada\/","title":{"rendered":"Consentement immigrant &#8211; HORS CANADA"},"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 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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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_31' style='display:none'><div id='gf_31' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_31' id='gform_31'  action='\/es\/wp-json\/wp\/v2\/pages\/49489#gf_31' data-formid='31' novalidate>\n        <div id='gf_progressbar_wrapper_31' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_31_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_31' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_31_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Consentement relative aux lois d\u2019application et \u00e0 la comp\u00e9tence judiciaire pour un m\u00e9decin Canadien et une personne non Canadienne.<\/h3><\/div><fieldset id=\"field_31_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >PATIENT : Nom complet comme sur le passeport<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_31_1'>\n                            \n                            <span id='input_31_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_31_1_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                    <input type='text' name='input_1.3' id='input_31_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_31_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_31_1_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_1.6' id='input_31_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_31_4\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_31_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_31_4_1_container' >\n                                        <label for='input_31_4_1' id='input_31_4_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                        <input type='text' name='input_4.1' id='input_31_4_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_31_4_3_container' >\n                                    <label for='input_31_4_3' id='input_31_4_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                    <input type='text' name='input_4.3' id='input_31_4_3' value=''    aria-required='false'   autocomplete=\"address-level2\" \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_4.4' id='input_31_4_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_31_4_5_container' >\n                                    <label for='input_31_4_5' id='input_31_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                    <input type='text' name='input_4.5' id='input_31_4_5' value=''    aria-required='false'   autocomplete=\"postal-code\" \/>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_31_4_6_container' >\n                                        <label for='input_31_4_6' id='input_31_4_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                        <select name='input_4.6' id='input_31_4_6'   aria-required='false'   autocomplete=\"country-name\" ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_31_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_31_2_container'>\n                                <span id='input_31_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_31_2' class='gform-field-label gform-field-label--type-sub '>Email Address<\/label>\n                                    <input class='' type='email' name='input_2' id='input_31_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_31_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_31_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_31_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_31_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_31_5'>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_5' id='input_31_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_31_28' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_31_2' class='gform_page' data-js='page-field-id-28' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_31_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_31_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Lois d\u2019application<\/h3><\/div><div id=\"field_31_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_31_17'>Je (inscrire votre nom complet comme sur votre passeport)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_31_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_31_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Par la pr\u00e9sente :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_31_16'><div class='gchoice gchoice_31_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='a)\treconnais que tous les aspects de la relation avec le docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier ainsi que ses mandataires, d\u00e9l\u00e9gu\u00e9(e)s, employ\u00e9(e)s, m\u00e9decins et autres professionnel(le)s de la sant\u00e9 ind\u00e9pendant(e)s qui m\u2019administrent des services m\u00e9dicaux ou autres soins et traitements de sant\u00e9 sans limitation que les conflits d\u00e9coulant de ma relation avecle docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier seront r\u00e9gis et interpr\u00e9t\u00e9s conform\u00e9ment aux lois de la province ou du territoire de Qu\u00e9bec et aux lois du Canada s\u2019y appliquant. b)\treconnais que le r\u00e8glement de tous les conflits d\u00e9coulant de cette relation ou y \u00e9tant reli\u00e9s, y compris les conflits d\u00e9coulant du pr\u00e9sent consentement ou s\u2019y rapportant seront r\u00e9gis et interpr\u00e9t\u00e9s conform\u00e9ment aux lois de la province ou du territoire de Qu\u00e9bec et aux lois du Canada s\u2019y appliquant.'  id='choice_31_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_16_1' id='label_31_16_1' class='gform-field-label gform-field-label--type-inline'>a)\treconnais que tous les aspects de la relation avec le docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier ainsi que ses mandataires, d\u00e9l\u00e9gu\u00e9(e)s, employ\u00e9(e)s, m\u00e9decins et autres professionnel(le)s de la sant\u00e9 ind\u00e9pendant(e)s qui m\u2019administrent des services m\u00e9dicaux ou autres soins et traitements de sant\u00e9 sans limitation que les conflits d\u00e9coulant de ma relation avecle docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier seront r\u00e9gis et interpr\u00e9t\u00e9s conform\u00e9ment aux lois de la province ou du territoire de Qu\u00e9bec et aux lois du Canada s\u2019y appliquant. b)\treconnais que le r\u00e8glement de tous les conflits d\u00e9coulant de cette relation ou y \u00e9tant reli\u00e9s, y compris les conflits d\u00e9coulant du pr\u00e9sent consentement ou s\u2019y rapportant seront r\u00e9gis et interpr\u00e9t\u00e9s conform\u00e9ment aux lois de la province ou du territoire de Qu\u00e9bec et aux lois du Canada s\u2019y appliquant.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_31_30' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_31_30' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_31_3' class='gform_page' data-js='page-field-id-30' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_31_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_31_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Comp\u00e9tence exclusive<\/h3><\/div><div id=\"field_31_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_31_19'>Je (inscrire votre nom complet comme sur votre passeport)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_31_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_31_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Par la pr\u00e9sente :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_31_18'><div class='gchoice gchoice_31_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='c)\treconnais que les services m\u00e9dicaux ou autres soins et traitements de sant\u00e9 que je re\u00e7ois du docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier seront administr\u00e9s dans la province de Qu\u00e9bec et que les tribunaux de la ville de Montr\u00e9al de la province de Qu\u00e9bec auront la comp\u00e9tence exclusive d\u2019entendre toute plainte, demande, r\u00e9clamation, proc\u00e9dure ou cause d\u2019action de quelque nature que ce soit d\u00e9coulant de ces services m\u00e9dicaux ou autres soins et traitements de sant\u00e9, ou de tout autre aspect de la relation entre moi et le docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier ou s\u2019y rapportant.'  id='choice_31_18_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_18_1' id='label_31_18_1' class='gform-field-label gform-field-label--type-inline'>c)\treconnais que les services m\u00e9dicaux ou autres soins et traitements de sant\u00e9 que je re\u00e7ois du docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier seront administr\u00e9s dans la province de Qu\u00e9bec et que les tribunaux de la ville de Montr\u00e9al de la province de Qu\u00e9bec auront la comp\u00e9tence exclusive d\u2019entendre toute plainte, demande, r\u00e9clamation, proc\u00e9dure ou cause d\u2019action de quelque nature que ce soit d\u00e9coulant de ces services m\u00e9dicaux ou autres soins et traitements de sant\u00e9, ou de tout autre aspect de la relation entre moi et le docteur travaillant chez SECURIMED inscrit \u00e0 mon dossier ou s\u2019y rapportant.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_31_29' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_31_29' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_31_4' class='gform_page' data-js='page-field-id-29' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_31_4' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_31_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Confirmation<\/h3><\/div><fieldset id=\"field_31_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Par la pr\u00e9sente :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_31_22'><div class='gchoice gchoice_31_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='J\u2019atteste, au mieux de mes connaissances, la v\u00e9racit\u00e9 et l\u2019exactitude des renseignements que j\u2019ai fournis dans la pr\u00e9sente. Avant de signer la pr\u00e9sente autorisation, je l\u2019ai lue et j\u2019en comprends enti\u00e8rement toutes les clauses ainsi que leurs port\u00e9es.'  id='choice_31_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_31_22_1' id='label_31_22_1' class='gform-field-label gform-field-label--type-inline'>J\u2019atteste, au mieux de mes connaissances, la v\u00e9racit\u00e9 et l\u2019exactitude des renseignements que j\u2019ai fournis dans la pr\u00e9sente. Avant de signer la pr\u00e9sente autorisation, je l\u2019ai lue et j\u2019en comprends enti\u00e8rement toutes les clauses ainsi que leurs port\u00e9es.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_31_24\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_31_24'>Date<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_24' id='input_31_24' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_31_24_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_31_24_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_31_24' class='gform_hidden' value='https:\/\/covid.securimed.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_31_25\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_31_25'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' 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contents;}jQuery('#gform_wrapper_31').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_31').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [31]);window['gf_submitting_31'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_31').text());}else{jQuery('#gform_31').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"31\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_31\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_31\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = 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