{"id":162,"date":"2024-10-23T10:34:51","date_gmt":"2024-10-23T14:34:01","guid":{"rendered":"\/?page_id=162"},"modified":"2025-04-08T17:20:17","modified_gmt":"2025-04-08T21:20:17","slug":"registre","status":"publish","type":"page","link":"https:\/\/uat.antechdiagnostics.com\/fr_ca\/imaging-services\/register\/","title":{"rendered":"Compte de services d&#039;imagerie \u2013 Inscription"},"content":{"rendered":"<div style=\"height:25px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-buttons is-layout-flex wp-block-buttons-is-layout-flex\">\n<div class=\"wp-block-button is-style-button-4\"><a class=\"wp-block-button__link wp-element-button\" href=\"\/fr_ca\/services-dimagerie\/\">&lt; Retour aux services d&#039;imagerie<\/a><\/div>\n<\/div>\n\n\n\n<div style=\"height:24px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h1 class=\"wp-block-heading is-style-heading-3-primary-bold\" style=\"padding-top:41;padding-right:41;padding-bottom:41;padding-left:41\">Compte de services d&#039;imagerie \u2013 Inscription<\/h1>\n\n\n\n<div style=\"height:22px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<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 InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indique les champs obligatoires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/fr_ca\/wp-json\/wp\/v2\/pages\/162#gf_2' data-formid='2' novalidate data-trp-original-action=\"\/fr_ca\/wp-json\/wp\/v2\/pages\/162#gf_2\"> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_68\" 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_2_68'>T\u00e9l\u00e9phone<\/label><div class='ginput_container'><input name='input_68' id='input_2_68' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_68'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><fieldset id=\"field_2_1\" 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' >Objectif principal de votre inscription aupr\u00e8s de Antech Imaging Services<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_1'>\n\t\t\t<div class='gchoice gchoice_2_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Send Consults for Interpretation'  id='choice_2_1_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_1_0' id='label_2_1_0' class='gform-field-label gform-field-label--type-inline'>Envoyer des consultations pour interpr\u00e9tation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='RapidRead AI Radiology Interpretation'  id='choice_2_1_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_1_1' id='label_2_1_1' class='gform-field-label gform-field-label--type-inline'>Interpr\u00e9tation radiologique RapidRead AI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_1_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='RapidRead AI Dental Interpretation'  id='choice_2_1_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_1_2' id='label_2_1_2' class='gform-field-label gform-field-label--type-inline'>Interpr\u00e9tation dentaire RapidRead AI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_1_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='PennHIP'  id='choice_2_1_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_1_3' id='label_2_1_3' class='gform-field-label gform-field-label--type-inline'>PennHIP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_1_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Data Storage'  id='choice_2_1_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_1_4' id='label_2_1_4' class='gform-field-label gform-field-label--type-inline'>Stockage de donn\u00e9es<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_65\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full 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' >Praticiens<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Pr\u00e9nom<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Nom de famille<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">E-mail<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_65_cell1 gform-grid-col' data-label='First Name'><input aria-invalid='false' aria-required=\"true\"  aria-label='Pr\u00e9nom, rang\u00e9e 1' data-aria-label-template='First Name, Row {0}' type='text' name='input_65[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_65_cell2 gform-grid-col' data-label='Last Name'><input aria-invalid='false' aria-required=\"true\"  aria-label='Nom de famille, ligne 1' data-aria-label-template='Last Name, Row {0}' type='text' name='input_65[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_65_cell3 gform-grid-col' data-label='Email'><input aria-invalid='false' aria-required=\"true\"  aria-label='Courriel, ligne 1' data-aria-label-template='Email, Row {0}' type='text' name='input_65[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 25)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 25)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_66\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full pointOfContact-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 du point de contact<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_2_66'>\n                            \n                            <span id='input_2_66_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.3' id='input_2_66_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                    <label for='input_2_66_3' class='gform-field-label gform-field-label--type-sub'>D&#039;abord<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_66_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_66.6' id='input_2_66_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                    <label for='input_2_66_6' class='gform-field-label gform-field-label--type-sub'>Dernier<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_56\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full pointOfContact-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_2_56'>Num\u00e9ro de t\u00e9l\u00e9phone du POC<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_56' id='input_2_56' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_57\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full pointOfContact-email 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' >Adresse e-mail du POC<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_2_57_container'>\n                                <span id='input_2_57_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_57' id='input_2_57' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                    <label for='input_2_57' class='gform-field-label gform-field-label--type-sub'>Entrez l&#039;e-mail<\/label>\n                                <\/span>\n                                <span id='input_2_57_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_57_2' id='input_2_57_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                    <label for='input_2_57_2' class='gform-field-label gform-field-label--type-sub'>Confirmez votre email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_2_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full practice-name 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_2_59'>Nom du cabinet<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_60\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full practice-address 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' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_2_60' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_60_1_container' >\n                                        <input type='text' name='input_60.1' id='input_2_60_1' value=''    aria-required='true'    \/>\n                                        <label for='input_2_60_1' id='input_2_60_1_label' class='gform-field-label gform-field-label--type-sub'>Adresse de la rue<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_2_60_2_container' >\n                                        <input type='text' name='input_60.2' id='input_2_60_2' value=''     aria-required='false'   \/>\n                                        <label for='input_2_60_2' id='input_2_60_2_label' class='gform-field-label gform-field-label--type-sub'>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_60_3_container' >\n                                    <input type='text' name='input_60.3' id='input_2_60_3' value=''    aria-required='true'    \/>\n                                    <label for='input_2_60_3' id='input_2_60_3_label' class='gform-field-label gform-field-label--type-sub'>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_60_4_container' >\n                                        <input type='text' name='input_60.4' id='input_2_60_4' value=''      aria-required='true'    \/>\n                                        <label for='input_2_60_4' id='input_2_60_4_label' class='gform-field-label gform-field-label--type-sub'>Etat \/ Province \/ R\u00e9gion<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_60_5_container' >\n                                    <input type='text' name='input_60.5' id='input_2_60_5' value=''    aria-required='true'    \/>\n                                    <label for='input_2_60_5' id='input_2_60_5_label' class='gform-field-label gform-field-label--type-sub'>Zip \/ code postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_2_60_6_container' >\n                                        <select name='input_60.6' id='input_2_60_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albanie<\/option><option value='Algeria' >Alg\u00e9rie<\/option><option value='American Samoa' >Samoa am\u00e9ricaines<\/option><option value='Andorra' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctique<\/option><option value='Antigua and Barbuda' >Antigua-et-Barbuda<\/option><option value='Argentina' >Argentine<\/option><option value='Armenia' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australie<\/option><option value='Austria' >Autriche<\/option><option value='Azerbaijan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbade<\/option><option value='Belarus' >Bi\u00e9lorussie<\/option><option value='Belgium' >Belgique<\/option><option value='Belize' >B\u00e9lize<\/option><option value='Benin' >B\u00e9nin<\/option><option value='Bermuda' >Bermudes<\/option><option value='Bhutan' >Bhoutan<\/option><option value='Bolivia' >Bolivie<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Saint-Eustache et Saba<\/option><option value='Bosnia and Herzegovina' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >\u00cele Bouvet<\/option><option value='Brazil' >Br\u00e9sil<\/option><option value='British Indian Ocean Territory' >Territoire britannique de l&#039;oc\u00e9an Indien<\/option><option value='Brunei Darussalam' >Brun\u00e9i Darussalam<\/option><option value='Bulgaria' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cap-Vert<\/option><option value='Cambodia' >Cambodge<\/option><option value='Cameroon' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >\u00celes Ca\u00efmans<\/option><option value='Central African Republic' >R\u00e9publique centrafricaine<\/option><option value='Chad' >Tchad<\/option><option value='Chile' >Chili<\/option><option value='China' >Chine<\/option><option value='Christmas Island' >L&#039;\u00eele Christmas<\/option><option value='Cocos Islands' >\u00celes Cocos<\/option><option value='Colombia' >Colombie<\/option><option value='Comoros' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, R\u00e9publique d\u00e9mocratique du<\/option><option value='Cook Islands' >\u00celes Cook<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Chypre<\/option><option value='Czechia' >Tch\u00e9quie<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominique<\/option><option value='Dominican Republic' >R\u00e9publique dominicaine<\/option><option value='Ecuador' >\u00c9quateur<\/option><option value='Egypt' >Egypte<\/option><option value='El Salvador' >Le Salvador<\/option><option value='Equatorial Guinea' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Eritrea' >\u00c9rythr\u00e9e<\/option><option value='Estonia' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopie<\/option><option value='Falkland Islands' >\u00celes Malouines<\/option><option value='Faroe Islands' >\u00celes F\u00e9ro\u00e9<\/option><option value='Fiji' >Fidji<\/option><option value='Finland' >Finlande<\/option><option value='France' >France<\/option><option value='French Guiana' >Guyane fran\u00e7aise<\/option><option value='French Polynesia' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='French Southern Territories' >Terres australes fran\u00e7aises<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambie<\/option><option value='Georgia' >G\u00e9orgie<\/option><option value='Germany' >Allemagne<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Gr\u00e8ce<\/option><option value='Greenland' >Groenland<\/option><option value='Grenada' >Grenade<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernesey<\/option><option value='Guinea' >Guin\u00e9e<\/option><option value='Guinea-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyana' >Guyane<\/option><option value='Haiti' >Ha\u00efti<\/option><option value='Heard Island and McDonald Islands' >\u00celes Heard et McDonald<\/option><option value='Holy See' >Saint-Si\u00e8ge<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hongrie<\/option><option value='Iceland' >Islande<\/option><option value='India' >Inde<\/option><option value='Indonesia' >Indon\u00e9sie<\/option><option value='Iran' >L&#039;Iran<\/option><option value='Iraq' >Irak<\/option><option value='Ireland' >Irlande<\/option><option value='Isle of Man' >\u00cele de Man<\/option><option value='Israel' >Isra\u00ebl<\/option><option value='Italy' >Italie<\/option><option value='Jamaica' >Jama\u00efque<\/option><option value='Japan' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Cor\u00e9e, R\u00e9publique populaire d\u00e9mocratique de<\/option><option value='Korea, Republic of' >Cor\u00e9e, R\u00e9publique de<\/option><option value='Kuwait' >Koweit<\/option><option value='Kyrgyzstan' >Kirghizistan<\/option><option value='Lao People&#039;s Democratic Republic' >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value='Latvia' >Lettonie<\/option><option value='Lebanon' >Liban<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Lib\u00e9ria<\/option><option value='Libya' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaisie<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malte<\/option><option value='Marshall Islands' >\u00celes Marshall<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritanie<\/option><option value='Mauritius' >Maurice<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexique<\/option><option value='Micronesia' >Micron\u00e9sie<\/option><option value='Moldova' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolie<\/option><option value='Montenegro' >Mont\u00e9n\u00e9gro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Maroc<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Birmanie<\/option><option value='Namibia' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >N\u00e9pal<\/option><option value='Netherlands' >Pays-Bas<\/option><option value='New Caledonia' >Nouvelle-Cal\u00e9donie<\/option><option value='New Zealand' >Nouvelle-Z\u00e9lande<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >\u00cele Norfolk<\/option><option value='North Macedonia' >Mac\u00e9doine du Nord<\/option><option value='Northern Mariana Islands' >\u00celes Mariannes du Nord<\/option><option value='Norway' >Norv\u00e8ge<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palaos<\/option><option value='Palestine, State of' >Palestine, \u00c9tat de<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >P\u00e9rou<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Pologne<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Porto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Roumanie<\/option><option value='Russian Federation' >F\u00e9d\u00e9ration de Russie<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint-Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint-Kitts-et-Nevis<\/option><option value='Saint Lucia' >Sainte-Lucie<\/option><option value='Saint Martin' >Saint-Martin<\/option><option value='Saint Pierre and Miquelon' >Saint-Pierre-et-Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >Saint-Marin<\/option><option value='Sao Tome and Principe' >Sao Tom\u00e9-et-Principe<\/option><option value='Saudi Arabia' >Arabie Saoudite<\/option><option value='Senegal' >S\u00e9n\u00e9gal<\/option><option value='Serbia' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapour<\/option><option value='Sint Maarten' >Saint-Martin<\/option><option value='Slovakia' >Slovaquie<\/option><option value='Slovenia' >Slov\u00e9nie<\/option><option value='Solomon Islands' >\u00celes Salomon<\/option><option value='Somalia' >Somalie<\/option><option value='South Africa' >Afrique du Sud<\/option><option value='South Georgia and the South Sandwich Islands' >G\u00e9orgie du Sud et les \u00eeles Sandwich du Sud<\/option><option value='South Sudan' >Soudan du Sud<\/option><option value='Spain' >Espagne<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Soudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard et Jan Mayen<\/option><option value='Sweden' >Su\u00e8de<\/option><option value='Switzerland' >Suisse<\/option><option value='Syria Arab Republic' >R\u00e9publique arabe syrienne<\/option><option value='Taiwan' >Ta\u00efwan<\/option><option value='Tajikistan' >Tadjikistan<\/option><option value='Tanzania, the United Republic of' >Tanzanie, R\u00e9publique-Unie de<\/option><option value='Thailand' >Tha\u00eflande<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Aller<\/option><option value='Tokelau' >Tok\u00e9laou<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinit\u00e9-et-Tobago<\/option><option value='Tunisia' >Tunisie<\/option><option value='Turkmenistan' >Turkm\u00e9nistan<\/option><option value='Turks and Caicos Islands' >\u00celes Turques-et-Ca\u00efques<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >Turquie<\/option><option value='US Minor Outlying Islands' >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='Uganda' >Ouganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >\u00c9mirats arabes unis<\/option><option value='United Kingdom' >Royaume-Uni<\/option><option value='United States' selected='selected'>\u00c9tats-Unis<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Ouzb\u00e9kistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Vietnam<\/option><option value='Virgin Islands, British' >\u00celes Vierges britanniques<\/option><option value='Virgin Islands, U.S.' >\u00celes Vierges am\u00e9ricaines<\/option><option value='Wallis and Futuna' >Wallis-et-Futuna<\/option><option value='Western Sahara' >Sahara occidental<\/option><option value='Yemen' >Y\u00e9men<\/option><option value='Zambia' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00celes \u00c5land<\/option><\/select>\n                                        <label for='input_2_60_6' id='input_2_60_6_label' class='gform-field-label gform-field-label--type-sub'>Pays<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_61\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_2_61'>Num\u00e9ro de t\u00e9l\u00e9phone du cabinet<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_61' id='input_2_61' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_67'>Extension<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_2_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_62\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full practice-email 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' >Adresse e-mail de pratique<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_2_62_container'>\n                                <span id='input_2_62_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_62' id='input_2_62' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_2_62' class='gform-field-label gform-field-label--type-sub'>Entrez l&#039;e-mail<\/label>\n                                <\/span>\n                                <span id='input_2_62_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_62_2' id='input_2_62_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_2_62_2' class='gform-field-label gform-field-label--type-sub'>Confirmez votre email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_2_64\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_64'>CAPTCHA<\/label><div id='input_2_64' class='ginput_container ginput_recaptcha' data-sitekey='6LdKbMEqAAAAABi_M7m6CTZve7LCe3UzExZX0ayg'  data-theme='light' data-tabindex='-1' data-size='invisible' data-badge='bottomright'><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=orbital&amp;styles={&quot;inputPrimaryColor&quot;:&quot;#463797&quot;,&quot;buttonPrimaryBackgroundColor&quot;:&quot;#463797&quot;}&amp;hash=3116c2f17046c37081012b1b0f5c8b4e' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='orbital' \/>\n            <input 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