{"id":786,"date":"2026-06-03T14:35:28","date_gmt":"2026-06-03T14:35:28","guid":{"rendered":"https:\/\/lumora-raio.com\/?page_id=786"},"modified":"2026-06-03T14:35:31","modified_gmt":"2026-06-03T14:35:31","slug":"pre-consultation-medical-questionnaire-fr","status":"publish","type":"page","link":"https:\/\/lumora-raio.com\/fr\/pre-consultation-medical-questionnaire-fr\/","title":{"rendered":"Pre-Consultation Medical Questionnaire FR"},"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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var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/786#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_39\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_39'>X\/Twitter<\/label><div class='ginput_container'><input name='input_39' id='input_3_39' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_39'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><div id=\"field_3_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">1.Informations personnelles<\/h3><div class='gsection_description' id='gfield_description_3_1'>Veuillez compl\u00e9ter toutes les informations personnelles requises.\n<\/div><\/div><fieldset id=\"field_3_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom et pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/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_3_3'>\n                            \n                            <span id='input_3_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_3_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_3_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_3_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_3_3_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_4' id='input_3_4' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_3_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_4_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_4' class='gform_hidden' value='https:\/\/lumora-raio.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_5'>Adresse e-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_3_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_3_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Pays de r\u00e9sidence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_3_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Nationalit\u00e9<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>Profession<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Langue pr\u00e9f\u00e9r\u00e9e pour la consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_3_10' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Rom\u00e2n\u0103' >Rom\u00e2n\u0103<\/option><option value='Fran\u00e7ais' >Fran\u00e7ais<\/option><option value='\u0420\u0443\u0441\u0441\u043a\u0438\u0439' >\u0420\u0443\u0441\u0441\u043a\u0438\u0439<\/option><option value='English' >English<\/option><\/select><\/div><\/div><div id=\"field_3_11\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'>\u00c9tat civil<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_3_11' class='large gfield_select'     aria-invalid=\"false\" ><option value='Nec\u0103s\u0103torit\u0103' >Nec\u0103s\u0103torit\u0103<\/option><option value='C\u0103s\u0103torit\u0103' >C\u0103s\u0103torit\u0103<\/option><option value='Divor\u021bat\u0103' >Divor\u021bat\u0103<\/option><option value='V\u0103duv\u0103' >V\u0103duv\u0103<\/option><option value='Alt\u0103 situa\u021bie' >Alt\u0103 situa\u021bie<\/option><\/select><\/div><\/div><div id=\"field_3_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">2.Type de consultation demand\u00e9e<\/h3><\/div><fieldset id=\"field_3_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Type de consultation demand\u00e9e<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_13'>\n\t\t\t<div class='gchoice gchoice_3_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Consultation gyn\u00e9cologique en ligne \u2014 100\u20ac'  id='choice_3_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_13_0' id='label_3_13_0' class='gform-field-label gform-field-label--type-inline'>Consultation gyn\u00e9cologique en ligne \u2014 100\u20ac<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Deuxi\u00e8me avis gyn\u00e9cologique avanc\u00e9 \u2014 170\u20ac'  id='choice_3_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_13_1' id='label_3_13_1' class='gform-field-label gform-field-label--type-inline'>Deuxi\u00e8me avis gyn\u00e9cologique avanc\u00e9 \u2014 170\u20ac<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Cr\u00e9neau pr\u00e9f\u00e9r\u00e9 pour la consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_14'>\n\t\t\t<div class='gchoice gchoice_3_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Lundi soir \u2014 consultations en ligne disponibles entre 19h30 et 20h30 (heure de Paris)'  id='choice_3_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_14_0' id='label_3_14_0' class='gform-field-label gform-field-label--type-inline'>Lundi soir \u2014 consultations en ligne disponibles entre 19h30 et 20h30 (heure de Paris)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Jeudi soir \u2014 consultations en ligne disponibles entre 19h30 et 20h30 (heure de Paris)'  id='choice_3_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_14_1' id='label_3_14_1' class='gform-field-label gform-field-label--type-inline'>Jeudi soir \u2014 consultations en ligne disponibles entre 19h30 et 20h30 (heure de Paris)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_16\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>Demande de rendez-vous rapide \/ cr\u00e9neau diff\u00e9rent<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_3_16' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_16\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_16'>Demande de rendez-vous rapide ou en dehors des cr\u00e9neaux habituels (selon disponibilit\u00e9 et pouvant entra\u00eener des frais suppl\u00e9mentaires).<\/div><\/div><div id=\"field_3_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">3. Motif de la consultation<\/h3><\/div><div id=\"field_3_18\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_18'>Motif principal de la consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_3_18' class='textarea large'  aria-describedby=\"gfield_description_3_18\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_18'>Veuillez d\u00e9crire le motif de votre consultation, les principaux sympt\u00f4mes, leur date d\u2019apparition, leur \u00e9volution dans le temps, les sympt\u00f4mes ou circonstances associ\u00e9s, ainsi que les facteurs qui les aggravent ou les soulagent.<\/div><\/div><div id=\"field_3_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">4. Ant\u00e9c\u00e9dents personnels physiologiques<\/h3><\/div><div id=\"field_3_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_21'>Menstruations et caract\u00e9ristiques du cycle menstruel<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_3_21' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_21\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_21'>\u00c2ge des premi\u00e8res r\u00e8gles, r\u00e9gularisation \u00e9ventuelle des cycles au cours de la premi\u00e8re ann\u00e9e, caract\u00e9ristiques actuelles du cycle menstruel, dur\u00e9e des cycles, dur\u00e9e des r\u00e8gles, abondance ou caract\u00e8re douloureux des menstruations, ainsi que tout autre sympt\u00f4me associ\u00e9.<\/div><\/div><div id=\"field_3_22\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_22'>Activit\u00e9 sexuelle<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_3_22' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_22\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_22'>D\u00e9but de la vie sexuelle, existence \u00e9ventuelle d\u2019un partenaire stable, activit\u00e9 sexuelle actuelle, g\u00eane ou douleur lors des rapports sexuels, saignements apr\u00e8s les rapports sexuels, ainsi qu\u2019ant\u00e9c\u00e9dents d\u2019infections g\u00e9nitales ou d\u2019infections sexuellement transmissibles.<\/div><\/div><div id=\"field_3_23\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>Contraception<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_3_23' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_23\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_23'>M\u00e9thodes contraceptives utilis\u00e9es actuellement ou par le pass\u00e9, tol\u00e9rance \u00e0 la contraception hormonale, ainsi que tout effet ind\u00e9sirable ou complication \u00e9ventuelle.<\/div><\/div><div id=\"field_3_24\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_24'>Ant\u00e9c\u00e9dents obst\u00e9tricaux<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_3_24' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_24\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_24'>Nombre de grossesses, d\u2019accouchements, d\u2019accouchements par voie basse, de c\u00e9sariennes, de fausses couches spontan\u00e9es ou provoqu\u00e9es, de grossesses extra-ut\u00e9rines, complications survenues pendant la grossesse, ainsi que tout traitement \u00e9ventuel pour infertilit\u00e9.<\/div><\/div><div id=\"field_3_25\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_25'>M\u00e9nopause \/ P\u00e9rim\u00e9nopause<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_3_25' type='text' value='' class='large'  aria-describedby=\"gfield_description_3_25\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_3_25'>M\u00e9nopause ou p\u00e9rim\u00e9nopause, \u00e2ge de survenue de la m\u00e9nopause, sympt\u00f4mes associ\u00e9s, traitements hormonaux utilis\u00e9s et \u00e9volution des sympt\u00f4mes au fil du temps.<\/div><\/div><div id=\"field_3_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_27'>Mode de vie et facteurs g\u00e9n\u00e9raux<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_3_27' class='textarea large'  aria-describedby=\"gfield_description_3_27\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_27'>Taille, poids, activit\u00e9 physique, habitudes alimentaires, \u00e9ventuelles expositions professionnelles, stress professionnel, horaires de travail, tabagisme, consommation d\u2019alcool, autres habitudes ou addictions, allergies connues, ainsi que toute autre information g\u00e9n\u00e9rale importante concernant votre mode de vie.<\/div><\/div><div id=\"field_3_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">5. Ant\u00e9c\u00e9dents familiaux<\/h3><\/div><div id=\"field_3_29\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_29'>Ant\u00e9c\u00e9dents familiaux importants : cancer du sein, de l\u2019ovaire, de l\u2019ut\u00e9rus ou colorectal, endom\u00e9triose, infertilit\u00e9, thromboses, maladies endocriniennes, maladies auto-immunes ou toute autre affection familiale importante.<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_3_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">6. Ant\u00e9c\u00e9dents m\u00e9dicaux personnels<\/h3><\/div><div id=\"field_3_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_32'>Affections m\u00e9dicales et gyn\u00e9cologiques diagnostiqu\u00e9es ant\u00e9rieurement, interventions chirurgicales, hospitalisations, infections importantes, traumatismes, \u00e9volution de ces affections ainsi que toute complication \u00e9ventuelle.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_3_32' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_34'>Traitement en cours<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_3_34' class='textarea large'  aria-describedby=\"gfield_description_3_34\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_3_34'>Traitement actuellement suivi pour des maladies chroniques ou d\u2019autres probl\u00e8mes m\u00e9dicaux, y compris les traitements hormonaux, les m\u00e9dicaments r\u00e9guliers et les compl\u00e9ments alimentaires.<\/div><\/div><div id=\"field_3_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">7. Documents m\u00e9dicaux<\/h3><div class='gsection_description' id='gfield_description_3_35'>Analyses biologiques, \u00e9chographies, IRM\/CT, r\u00e9sultats HPV\/Frottis cervico-ut\u00e9rin (Pap test), courriers m\u00e9dicaux, comptes rendus op\u00e9ratoires, r\u00e9sultats anatomopathologiques ou tout autre document m\u00e9dical pertinent.\n\nV\u0103 rug\u0103m s\u0103 \u00eenc\u0103rca\u021bi concluziile \u0219i rapoartele medicale oficiale disponibile. Interpretarea investiga\u021biilor imagistice \u0219i paraclinice trebuie realizat\u0103 de c\u0103tre medicul specialist care a efectuat sau validat investiga\u021bia respectiv\u0103.\n\n<\/div><\/div><div id=\"field_3_36\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_3_36'>Veuillez t\u00e9l\u00e9charger les documents m\u00e9dicaux pertinents disponibles. Ils doivent \u00eatre transmis au moins 48 heures avant le cr\u00e9neau choisi pour la consultation.<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_3_36' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_3_36&quot;,&quot;container&quot;:&quot;gform_multifile_upload_3_36&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_3_36&quot;,&quot;filelist&quot;:&quot;gform_preview_3_36&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/lumora-raio.com\\\/?gf_page=6d2874bcae919b3&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/lumora-raio.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/lumora-raio.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;8388608b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:3,&quot;field_id&quot;:36,&quot;_gform_file_upload_nonce_3_36&quot;:&quot;3c959c308c&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_3_36&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_3_36' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_3_36' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_3_36 gfield_description_3_36\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_3_36'>Taille max. des fichiers\u00a0: 8 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_3_36'><\/ul> <div id='gform_preview_3_36' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_3_36'>Veuillez t\u00e9l\u00e9charger les conclusions et les rapports m\u00e9dicaux officiels disponibles. L\u2019interpr\u00e9tation des examens d\u2019imagerie et des investigations paracliniques doit \u00eatre r\u00e9alis\u00e9e par le m\u00e9decin sp\u00e9cialiste ayant effectu\u00e9 ou valid\u00e9 l\u2019examen concern\u00e9.<\/div><\/div><div id=\"field_3_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">8. Consentement et confirmation<\/h3><\/div><fieldset id=\"field_3_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Je confirme les \u00e9l\u00e9ments suivants :<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_38'><div class='gchoice gchoice_3_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Les informations fournies sont exactes et compl\u00e8tes.'  id='choice_3_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_1' id='label_3_38_1' class='gform-field-label gform-field-label--type-inline'>Les informations fournies sont exactes et compl\u00e8tes.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Je comprends les limites d\u2019une consultation en ligne en l\u2019absence d\u2019un examen clinique direct.'  id='choice_3_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_2' id='label_3_38_2' class='gform-field-label gform-field-label--type-inline'>Je comprends les limites d\u2019une consultation en ligne en l\u2019absence d\u2019un examen clinique direct.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Je comprends que ce service ne remplace pas une prise en charge m\u00e9dicale d\u2019urgence.'  id='choice_3_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_3' id='label_3_38_3' class='gform-field-label gform-field-label--type-inline'>Je comprends que ce service ne remplace pas une prise en charge m\u00e9dicale d\u2019urgence.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='J\u2019accepte le traitement et le stockage s\u00e9curis\u00e9s de mes donn\u00e9es m\u00e9dicales \u00e0 des fins m\u00e9dicales.'  id='choice_3_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_4' id='label_3_38_4' class='gform-field-label gform-field-label--type-inline'>J\u2019accepte le traitement et le stockage s\u00e9curis\u00e9s de mes donn\u00e9es m\u00e9dicales \u00e0 des fins m\u00e9dicales.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='J\u2019accepte l\u2019utilisation de syst\u00e8mes informatiques et d\u2019outils d\u2019intelligence artificielle comme aide \u00e0 l\u2019analyse m\u00e9dicale, sous supervision m\u00e9dicale.'  id='choice_3_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_5' id='label_3_38_5' class='gform-field-label gform-field-label--type-inline'>J\u2019accepte l\u2019utilisation de syst\u00e8mes informatiques et d\u2019outils d\u2019intelligence artificielle comme aide \u00e0 l\u2019analyse m\u00e9dicale, sous supervision m\u00e9dicale.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Je confirme avoir lu, compris et accept\u00e9 les Conditions G\u00e9n\u00e9rales de la Consultation Gyn\u00e9cologique en Ligne, la Politique de Confidentialit\u00e9 (RGPD), la Politique d\u2019Annulation et de Remboursement ainsi que le Consentement \u00e0 la T\u00e9l\u00e9consultation, et j\u2019accepte le traitement, l\u2019utilisation et le stockage s\u00e9curis\u00e9s de mes donn\u00e9es et documents m\u00e9dicaux aux fins de consultation, d\u2019\u00e9valuation m\u00e9dicale, d\u2019orientation diagnostique, d\u2019obtention d\u2019un deuxi\u00e8me avis m\u00e9dical, de suivi m\u00e9dical et de toute autre finalit\u00e9 m\u00e9dicale connexe.'  id='choice_3_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_38_6' id='label_3_38_6' class='gform-field-label gform-field-label--type-inline'>Je confirme avoir lu, compris et accept\u00e9 les Conditions G\u00e9n\u00e9rales de la Consultation Gyn\u00e9cologique en Ligne, la Politique de Confidentialit\u00e9 (RGPD), la Politique d\u2019Annulation et de Remboursement ainsi que le Consentement \u00e0 la T\u00e9l\u00e9consultation, et j\u2019accepte le traitement, l\u2019utilisation et le stockage s\u00e9curis\u00e9s de mes donn\u00e9es et documents m\u00e9dicaux aux fins de consultation, d\u2019\u00e9valuation m\u00e9dicale, d\u2019orientation diagnostique, d\u2019obtention d\u2019un deuxi\u00e8me avis m\u00e9dical, de suivi m\u00e9dical et de toute autre finalit\u00e9 m\u00e9dicale 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