{"id":793,"date":"2026-06-03T15:49:46","date_gmt":"2026-06-03T15:49:46","guid":{"rendered":"https:\/\/lumora-raio.com\/?page_id=793"},"modified":"2026-06-03T15:49:48","modified_gmt":"2026-06-03T15:49:48","slug":"pre-consultation-medical-questionnaire-en","status":"publish","type":"page","link":"https:\/\/lumora-raio.com\/fr\/pre-consultation-medical-questionnaire-en\/","title":{"rendered":"Pre-Consultation Medical Questionnaire EN"},"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_5' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_5' id='gform_5'  action='\/fr\/wp-json\/wp\/v2\/pages\/793#gf_5' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_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_5_39'>Company<\/label><div class='ginput_container'><input name='input_39' id='input_5_39' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_39'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><div id=\"field_5_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. Personal Information<\/h3><div class='gsection_description' id='gfield_description_5_1'>Please complete all required personal information.<\/div><\/div><fieldset id=\"field_5_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' >First and Last Name<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_5_3'>\n                            \n                            <span id='input_5_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_5_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_5_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_3_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_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_5_4'>Date of Birth<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_5_4' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_4_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_4_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_4' class='gform_hidden' value='https:\/\/lumora-raio.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_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_5_5'>Email Address<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_5_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_5_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_5_6'>Telephone<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_5_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_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_5_7'>Country of Residence<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_5_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_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_5_8'>Nationality<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_5_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_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_5_9'>Profession<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_5_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_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_5_10'>Preferred Consultation Language<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_5_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_5_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_5_11'>Marital Status<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_5_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_5_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. Requested Consultation Type<\/h3><\/div><fieldset id=\"field_5_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' >Requested Consultation Type<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_5_13'>\n\t\t\t<div class='gchoice gchoice_5_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Online Gynecology Consultation \u2014 100 \u20ac'  id='choice_5_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_0' id='label_5_13_0' class='gform-field-label gform-field-label--type-inline'>Online Gynecology Consultation \u2014 100 \u20ac<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Advanced Gynecological Second Opinion \u2014 170 \u20ac'  id='choice_5_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>Advanced Gynecological Second Opinion \u2014 170 \u20ac<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_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' >Preferred Consultation Schedule<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_5_14'>\n\t\t\t<div class='gchoice gchoice_5_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Monday evening \u2014 online consultations available between 19:30\u201320:30 (Paris time)'  id='choice_5_14_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_14_0' id='label_5_14_0' class='gform-field-label gform-field-label--type-inline'>Monday evening \u2014 online consultations available between 19:30\u201320:30 (Paris time)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Thursday evening \u2014 online consultations available between 19:30\u201320:30 (Paris time)'  id='choice_5_14_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_14_1' id='label_5_14_1' class='gform-field-label gform-field-label--type-inline'>Thursday evening \u2014 online consultations available between 19:30\u201320:30 (Paris time)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_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_5_16'>Urgent Appointment Request \/ Alternative Time Slot<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_5_16' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_16\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_16'>Request for an urgent appointment or a consultation outside standard hours (subject to availability and possible additional fees).<\/div><\/div><div id=\"field_5_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. Reason for Consultation<\/h3><\/div><div id=\"field_5_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_5_18'>Main Reason for 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_5_18' class='textarea large'  aria-describedby=\"gfield_description_5_18\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_5_18'>Please describe the reason for your consultation, the main symptoms, when they started, how they have evolved over time, what they are associated with, and which factors aggravate or relieve them.<\/div><\/div><div id=\"field_5_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. Personal Physiological History<\/h3><\/div><div id=\"field_5_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_5_21'>Menstruation and Menstrual Cycle Characteristics<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_5_21' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_21\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_21'>Age at first menstruation, whether menstrual cycles became regular during the first year after onset, current menstrual cycle characteristics, cycle length, duration of menstruation, whether periods are heavy or painful, and any associated symptoms.abundente sau dureroase \u0219i dac\u0103 sunt \u00eenso\u021bite de alte simptome.<\/div><\/div><div id=\"field_5_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_5_22'>Sexual Activity<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_5_22' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_22\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_22'>Age at first sexual intercourse, presence of a stable partner, current sexual activity, discomfort or pain during sexual intercourse, bleeding after intercourse, and any history of genital infections or sexually transmitted infections.<\/div><\/div><div id=\"field_5_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_5_23'>Contraception<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_5_23' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_23\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_23'>Current or previous contraceptive methods, tolerance of hormonal contraception, and any side effects or complications.<\/div><\/div><div id=\"field_5_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_5_24'>Obstetrical History<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_5_24' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_24\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_24'>Number of pregnancies, deliveries, vaginal deliveries, cesarean sections, spontaneous or induced abortions, ectopic pregnancies, pregnancy complications, and any infertility treatments.infertilitate.<\/div><\/div><div id=\"field_5_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_5_25'>Menopause \/ Perimenopause<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_5_25' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_25\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_25'>Menopause or perimenopause, age at menopause onset, associated symptoms, hormonal treatments used, and evolution of symptoms over time.<\/div><\/div><div id=\"field_5_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_5_27'>Lifestyle and General Factors<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_5_27' class='textarea large'  aria-describedby=\"gfield_description_5_27\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_5_27'>Height, weight, physical activity, dietary habits, possible occupational exposures, work-related stress, work schedule, smoking, alcohol consumption, other habits, known allergies, and any other important lifestyle-related information.<\/div><\/div><div id=\"field_5_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. Family History<\/h3><\/div><div id=\"field_5_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_5_29'>Important family conditions: breast, ovarian, uterine or colorectal cancer, endometriosis, infertility, thrombosis, endocrine diseases, autoimmune diseases, or any other significant family medical conditions.<\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_5_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_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. Personal Medical History<\/h3><\/div><div id=\"field_5_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_5_32'>Previously diagnosed medical and gynecological conditions, surgical procedures, hospitalizations, significant infections, injuries, their evolution, and any complications.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_5_32' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_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_5_34'>Current Treatment<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_5_34' class='textarea large'  aria-describedby=\"gfield_description_5_34\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_5_34'>Treatment currently taken for chronic diseases or other medical conditions, including hormonal therapies, regular medications, and dietary supplements.<\/div><\/div><div id=\"field_5_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. Medical Documents<\/h3><div class='gsection_description' id='gfield_description_5_35'>Laboratory tests, ultrasound examinations, MRI\/CT scans, HPV\/Pap smear results, medical reports, operative reports, histopathology results, or any other relevant medical documents.<\/div><\/div><div id=\"field_5_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_5_36'>Please upload all available relevant medical documents. They must be submitted at least 48 hours before the selected consultation time.<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_5_36' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_5_36&quot;,&quot;container&quot;:&quot;gform_multifile_upload_5_36&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_5_36&quot;,&quot;filelist&quot;:&quot;gform_preview_5_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;:5,&quot;field_id&quot;:36,&quot;_gform_file_upload_nonce_5_36&quot;:&quot;74a4cad317&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_5_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_5_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_5_36' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_5_36 gfield_description_5_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_5_36'>Taille max. des fichiers\u00a0: 8 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_5_36'><\/ul> <div id='gform_preview_5_36' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_5_36'>Please upload all available relevant medical documents. They must be submitted at least 48 hours before the selected consultation time.<\/div><\/div><div id=\"field_5_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. Consent and Confirmation<\/h3><\/div><fieldset id=\"field_5_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' >I confirm the following:<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_5_38'><div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='The information provided is accurate and complete.'  id='choice_5_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>The information provided is accurate and complete.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='I understand the limitations of an online consultation in the absence of a direct clinical examination.'  id='choice_5_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_2' id='label_5_38_2' class='gform-field-label gform-field-label--type-inline'>I understand the limitations of an online consultation in the absence of a direct clinical examination.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='I understand that this service does not replace emergency medical care.'  id='choice_5_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_3' id='label_5_38_3' class='gform-field-label gform-field-label--type-inline'>I understand that this service does not replace emergency medical care.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='I agree to the processing and secure storage of my medical data for medical purposes.'  id='choice_5_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_4' id='label_5_38_4' class='gform-field-label gform-field-label--type-inline'>I agree to the processing and secure storage of my medical data for medical purposes.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='I agree to the use of information systems and artificial intelligence technologies as support tools for medical analysis under medical supervision.'  id='choice_5_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_5' id='label_5_38_5' class='gform-field-label gform-field-label--type-inline'>I agree to the use of information systems and artificial intelligence technologies as support tools for medical analysis under medical supervision.<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='I confirm that I have read, understood, and accepted the Online Gynecology Consultation Terms &amp; Conditions, Privacy Policy (GDPR), Cancellation &amp; Refund Policy, and Teleconsultation Consent, and I consent to the processing, use, and secure storage of my medical data and documents for consultation, medical evaluation, diagnostic guidance, second-opinion review, follow-up care, and other related medical purposes.'  id='choice_5_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_38_6' id='label_5_38_6' class='gform-field-label gform-field-label--type-inline'>I confirm that I have read, understood, and accepted the Online Gynecology Consultation Terms &amp; Conditions, Privacy Policy (GDPR), Cancellation &amp; Refund Policy, and 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