{"id":1110,"date":"2018-03-14T05:06:51","date_gmt":"2018-03-14T05:06:51","guid":{"rendered":"https:\/\/crcquebec.com\/?page_id=1110"},"modified":"2026-02-26T14:45:42","modified_gmt":"2026-02-26T19:45:42","slug":"application-etape-1","status":"publish","type":"page","link":"https:\/\/crcquebec.com\/en\/application-etape-1\/","title":{"rendered":"Application \u00c9tape 1"},"content":{"rendered":"<div id=\"pl-1110\"  class=\"panel-layout\" ><div id=\"pg-1110-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-1110-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-1110-0-0-0\" class=\"so-panel widget widget_text panel-first-child panel-last-child\" data-index=\"0\" ><h3 class=\"widget-title\"><span class=\"widget-title__inline\">Medical consent form<\/span><\/h3>\t\t\t<div class=\"textwidget\"><\/div>\n\t\t<\/div><\/div><\/div><div id=\"pg-1110-1\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-1110-1-0\"  class=\"panel-grid-cell\" ><div id=\"panel-1110-1-0-0\" class=\"widget_text so-panel widget widget_custom_html panel-first-child panel-last-child\" data-index=\"1\" ><div class=\"widget_text medical_form_fr panel-widget-style panel-widget-style-for-1110-1-0-0\" ><div class=\"textwidget custom-html-widget\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1201 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1201\" data-uid=\"6a1c812f0a8f3\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-1201\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1201 forminator-design--material  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"1201\"\r\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"default\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6a1c812f0a8f3\" action=\"\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1201--page-0\"\r\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1201--page-0-label\"\r\n\t\t\t\tdata-step=\"0\"\r\n\t\t\t\tdata-label=\"5) Signature et Pi\u00e8ce d&#039;identit\u00e9\"\r\n\t\t\t\tdata-actual-label=\"1) Informations personnelles\"\r\n\t\t\t\tdata-name=\"page-break-1\"\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">1) Informations personnelles<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a1c812f0a8f3\" id=\"forminator-field-name-1_6a1c812f0a8f3-label\" class=\"forminator-label\">Full legal name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a1c812f0a8f3\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-form-1201__field--select-1_6a1c812f0a8f3\" id=\"forminator-form-1201__field--select-1_6a1c812f0a8f3-label\" class=\"forminator-label\">Genre <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-1201__field--select-1_6a1c812f0a8f3\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"S\u00e9lectionner votre genre\" data-search=\"false\" data-search-placeholder=\"S\u00e9lectionner votre genre\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1201__field--select-1_6a1c812f0a8f3-label\"><option value=\"\"  >S\u00e9lectionner votre genre<\/option><option value=\"one\"  data-calculation=\"0\">Femme<\/option><option value=\"two\"  data-calculation=\"0\">Homme<\/option><option value=\"Non-binaire\"  data-calculation=\"0\">Non-binaire<\/option><option value=\"Pr\u00e9f\u00e8re-ne-pas-r\u00e9pondre\"  data-calculation=\"0\">Pr\u00e9f\u00e8re ne pas r\u00e9pondre<\/option><\/select><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a1c812f0a8f3\" id=\"forminator-field-date-1-picker_6a1c812f0a8f3-label\" class=\"forminator-label\">Date de naissance <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choisir une date\" id=\"forminator-field-date-1-picker_6a1c812f0a8f3\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"yy-mm-dd\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a1c812f0a8f3\" id=\"forminator-field-email-1_6a1c812f0a8f3-label\" class=\"forminator-label\">Email address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a1c812f0a8f3\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a1c812f0a8f3\" id=\"forminator-field-phone-1_6a1c812f0a8f3-label\" class=\"forminator-label\">T\u00e9l\u00e9phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a1c812f0a8f3\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a1c812f0a8f3\" id=\"forminator-field-address-1-street_address_6a1c812f0a8f3-label\" class=\"forminator-label\">Adresse <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a1c812f0a8f3\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a1c812f0a8f3\" id=\"forminator-field-address-1-address_line_6a1c812f0a8f3-label\" class=\"forminator-label\">Appartement, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a1c812f0a8f3\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6a1c812f0a8f3\" id=\"forminator-field-address-1-city_6a1c812f0a8f3-label\" class=\"forminator-label\">Ville <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a1c812f0a8f3\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6a1c812f0a8f3\" id=\"forminator-field-address-1-state_6a1c812f0a8f3-label\" class=\"forminator-label\">Province <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a1c812f0a8f3\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a1c812f0a8f3\" id=\"forminator-field-address-1-zip_6a1c812f0a8f3-label\" class=\"forminator-label\">Code postal <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a1c812f0a8f3\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-10-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-10-6a1c812f0a8f3-label\" class=\"forminator-label\">\u00cates-vous un ancien combattant, un agent de la GRC ou un policier ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-10\" value=\"one\" id=\"forminator-field-radio-10-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Ancien combattant\"><input type=\"radio\" name=\"radio-10\" value=\"two\" id=\"forminator-field-radio-10-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Ancien combattant<\/span><\/label><label id=\"forminator-field-radio-10-label-3\" for=\"forminator-field-radio-10-3-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Agent de la GRC\"><input type=\"radio\" name=\"radio-10\" value=\"Agent-de-la-GRC\" id=\"forminator-field-radio-10-3-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-10-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Agent de la GRC<\/span><\/label><label id=\"forminator-field-radio-10-label-4\" for=\"forminator-field-radio-10-4-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Policier\"><input type=\"radio\" name=\"radio-10\" value=\"Policier\" id=\"forminator-field-radio-10-4-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-10-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Policier<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-form-1201__field--select-3_6a1c812f0a8f3\" id=\"forminator-form-1201__field--select-3_6a1c812f0a8f3-label\" class=\"forminator-label\">Comment avez-vous entendu parler de nous ?<\/label><select  id=\"forminator-form-1201__field--select-3_6a1c812f0a8f3\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Veuillez choisir\" data-search=\"false\" data-search-placeholder=\"Veuillez choisir\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1201__field--select-3_6a1c812f0a8f3-label\"><option value=\"\"  >Veuillez choisir<\/option><option value=\"one\"  data-calculation=\"0\">Moteur de recherche (Google \/ Bing \/ Etc)<\/option><option value=\"two\"  data-calculation=\"0\">R\u00e9seau sociaux (Facebook \/ Instagram \/ Tiktok)<\/option><option value=\"Recommandation-(ami---client)\"  data-calculation=\"0\">Recommandation (ami \/ client)<\/option><option value=\"D\u00e9j\u00e0-client\"  data-calculation=\"0\">D\u00e9j\u00e0 client<\/option><option value=\"Publicit\u00e9\"  data-calculation=\"0\">Publicit\u00e9<\/option><option value=\"custom_option\"  data-calculation=\"0\">Autre<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-1201__field--select-3_6a1c812f0a8f3\" name=\"custom-select-3\" class=\"forminator-input\" aria-label=\"Autre\" value=\"\" \/><\/div><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a1c812f0a8f3\" id=\"forminator-field-text-2_6a1c812f0a8f3-label\" class=\"forminator-label\">Code de r\u00e9f\u00e9rence<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a1c812f0a8f3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1201--page-1\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1201--page-1-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"1\"\r\n\t\t\t\tdata-label=\"1) Informations personnelles\"\r\n\t\t\t\tdata-actual-label=\"2) Historique m\u00e9dical\"\r\n\t\t\t\tdata-name=\"page-break-4\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">2) Historique m\u00e9dical<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a1c812f0a8f3\" id=\"forminator-field-textarea-1_6a1c812f0a8f3-label\" class=\"forminator-label\">Conditions m\u00e9dicales (pass\u00e9es ou actuelles)<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a1c812f0a8f3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a1c812f0a8f3\" id=\"forminator-field-textarea-2_6a1c812f0a8f3-label\" class=\"forminator-label\">M\u00e9dicaments (si oui, listez tout)<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a1c812f0a8f3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-9-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-9-6a1c812f0a8f3-label\" class=\"forminator-label\">Avez-vous des allergies ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-9\" value=\"one\" id=\"forminator-field-radio-9-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-9\" value=\"two\" id=\"forminator-field-radio-9-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a1c812f0a8f3\" id=\"forminator-field-text-1_6a1c812f0a8f3-label\" class=\"forminator-label\">Allergies<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a1c812f0a8f3\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-1-6a1c812f0a8f3-label\" class=\"forminator-label\">Ant\u00e9c\u00e9dents de schizophr\u00e9nie? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-2-6a1c812f0a8f3-label\" class=\"forminator-label\">\u00cates-vous enceinte \/ allaitement \/ planifie grossesse? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"N\/A\"><input type=\"radio\" name=\"radio-2\" value=\"N-A\" id=\"forminator-field-radio-2-3-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">N\/A<\/span><\/label><\/div><\/div><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-3-6a1c812f0a8f3-label\" class=\"forminator-label\">Maladie cardiaque? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-4-6a1c812f0a8f3-label\" class=\"forminator-label\">Maladie pulmonaire? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-5-6a1c812f0a8f3-label\" class=\"forminator-label\">Historique criminel li\u00e9 aux drogues \/ diversion? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-2_6a1c812f0a8f3\" id=\"forminator-field-upload-2_6a1c812f0a8f3-label\" class=\"forminator-label\">Fichiers m\u00e9dicaux (\u26a0\ufe0f Optionnel, mais acc\u00e9l\u00e8re grandement le processus.)<\/label><span id=\"forminator-field-upload-2_6a1c812f0a8f3-description\" class=\"forminator-description\">Historique de m\u00e9dication | Dossier m\u00e9dical | Prescription de cannabis m\u00e9dical ant\u00e9rieur | Permit de production ACMPR | Pot de m\u00e9dicament (photo)<\/span><div class=\"forminator-multi-upload\" data-element=\"upload-2_6a1c812f0a8f3\" aria-describedby=\"forminator-field-upload-2_6a1c812f0a8f3-description\"><input type=\"file\" name=\"upload-2[]\" id=\"forminator-field-upload-2_6a1c812f0a8f3\" class=\"forminator-input-file forminator-field-upload-2_6a1c812f0a8f3-1201\" multiple=\"multiple\" data-method=\"ajax\" accept=\".jpg,.jpeg,.jpe,.png,.webp,.avif,.heic,.heif,.heics,.heifs,.pdf\" data-limit=\"5\" data-limit-message=\"You can upload a maximum of 5 files.\" data-size=\"3000000\" data-size-message=\"Maximum file size allowed is 3 MB. \" data-filetype=\"jpg|jpeg|jpe|png|webp|avif|heic|heif|heics|heifs|pdf\" data-filetype-message=\"file extension is not allowed.\"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-2_6a1c812f0a8f3\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-2_6a1c812f0a8f3\"><\/ul><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1201--page-2\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1201--page-2-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"2\"\r\n\t\t\t\tdata-label=\"2) Historique m\u00e9dical\"\r\n\t\t\t\tdata-actual-label=\"3) Cannabis \u2013 exp\u00e9rience &amp; objectifs\"\r\n\t\t\t\tdata-name=\"page-break-2\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">3) Cannabis \u2013 exp\u00e9rience &amp; objectifs<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-6-6a1c812f0a8f3-label\" class=\"forminator-label\">Avez-vous d\u00e9j\u00e0 essay\u00e9 le cannabis? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-7-6a1c812f0a8f3-label\" class=\"forminator-label\">Prescription\/autorisation m\u00e9dicale dans le pass\u00e9?<\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_6a1c812f0a8f3\" id=\"forminator-field-number-1_6a1c812f0a8f3-label\" class=\"forminator-label\">Ann\u00e9es d\u2019utilisation (si applicable)<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_6a1c812f0a8f3\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a1c812f0a8f3\" id=\"forminator-field-textarea-3_6a1c812f0a8f3-label\" class=\"forminator-label\">Que souhaitez-vous traiter avec le cannabis? <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a1c812f0a8f3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6a1c812f0a8f3\" id=\"forminator-field-textarea-4_6a1c812f0a8f3-label\" class=\"forminator-label\">Qu\u2019avez-vous essay\u00e9 dans le pass\u00e9? (m\u00e9dicaments, th\u00e9rapie, massage, exercice\u2026) <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6a1c812f0a8f3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_6a1c812f0a8f3\" id=\"forminator-field-textarea-5_6a1c812f0a8f3-label\" class=\"forminator-label\">Si vous planifiez cultiver (raison m\u00e9dicale), que comptez-vous faire avec les plants? (huiles, comestibles, concentr\u00e9s, topiques\u2026)<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_6a1c812f0a8f3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-8-6a1c812f0a8f3-label\"><span id=\"forminator-radiogroup-radio-8-6a1c812f0a8f3-label\" class=\"forminator-label\">Utilisez-vous actuellement du cannabis? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Oui\"><input type=\"radio\" name=\"radio-8\" value=\"one\" id=\"forminator-field-radio-8-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-6a1c812f0a8f3\" class=\"forminator-radio forminator-radio-inline\" title=\"Non\"><input type=\"radio\" name=\"radio-8\" value=\"two\" id=\"forminator-field-radio-8-2-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-form-1201__field--select-2_6a1c812f0a8f3\" id=\"forminator-form-1201__field--select-2_6a1c812f0a8f3-label\" class=\"forminator-label\">Grammes requis (estimation) <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-1201__field--select-2_6a1c812f0a8f3\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-2\" data-default-value=\"one\" data-hidden-behavior=\"zero\" data-placeholder=\"Please select an option\" data-search=\"false\" data-search-placeholder=\"Please select an option\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1201__field--select-2_6a1c812f0a8f3-label\"><option value=\"\"  >Please select an option<\/option><option value=\"one\" selected=\"selected\" data-calculation=\"0\">5 Grammes<\/option><option value=\"two\"  data-calculation=\"0\">10 Grammes<\/option><option value=\"5-Grammes\"  data-calculation=\"0\">15 Grammes<\/option><option value=\"5-Grammes\"  data-calculation=\"0\">20 Grammes<\/option><option value=\"25\"  data-calculation=\"0\">25 Grammes<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6a1c812f0a8f3\" id=\"forminator-field-textarea-6_6a1c812f0a8f3-label\" class=\"forminator-label\">Si plus de 5g\/jour requis, expliquez pourquoi<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_6a1c812f0a8f3\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1201--page-3\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1201--page-3-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"3\"\r\n\t\t\t\tdata-label=\"3) Cannabis \u2013 exp\u00e9rience &amp; objectifs\"\r\n\t\t\t\tdata-actual-label=\"4) Conditions &amp; consentement\"\r\n\t\t\t\tdata-name=\"page-break-3\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">4) Conditions &amp; consentement<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12\"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><h2>1. Nature du service<\/h2>\n<p>Je comprends que cette \u00e9valuation vise \u00e0 d\u00e9terminer mon admissibilit\u00e9 \u00e0 une autorisation de cannabis m\u00e9dical conform\u00e9ment aux lois et r\u00e8glements applicables au Canada.<\/p>\n<p>Je reconnais que :<\/p>\n<ul>\n<li>Le professionnel de la sant\u00e9 base son \u00e9valuation sur les informations que je fournis.<\/li>\n<li>L\u2019autorisation n\u2019est pas garantie.<\/li>\n<li>Le professionnel peut refuser l\u2019autorisation si celle-ci est jug\u00e9e m\u00e9dicalement inappropri\u00e9e.<\/li>\n<\/ul>\n<hr>\n<h2>2. Exactitude des informations<\/h2>\n<p>Je confirme que :<\/p>\n<ul>\n<li>Toutes les informations fournies sont exactes, compl\u00e8tes et v\u00e9ridiques.<\/li>\n<li>J\u2019ai divulgu\u00e9 l\u2019ensemble de mes ant\u00e9c\u00e9dents m\u00e9dicaux, psychiatriques et m\u00e9dicamenteux.<\/li>\n<li>Toute fausse d\u00e9claration ou omission peut entra\u00eener un refus ou l\u2019annulation de l\u2019autorisation.<\/li>\n<\/ul>\n<hr>\n<h2>3. Risques m\u00e9dicaux et effets secondaires<\/h2>\n<p>Je comprends que le cannabis m\u00e9dical peut entra\u00eener certains effets secondaires, notamment :<\/p>\n<ul>\n<li>Somnolence<\/li>\n<li>Alt\u00e9ration de la coordination et du jugement<\/li>\n<li>Anxi\u00e9t\u00e9 ou parano\u00efa<\/li>\n<li>Acc\u00e9l\u00e9ration du rythme cardiaque<\/li>\n<li>Irritation respiratoire (si inhal\u00e9)<\/li>\n<\/ul>\n<p>Je comprends \u00e9galement que le cannabis peut :<\/p>\n<ul>\n<li>Interagir avec d\u2019autres m\u00e9dicaments<\/li>\n<li>Aggraver certaines conditions psychiatriques ou cardiovasculaires<\/li>\n<li>Alt\u00e9rer ma capacit\u00e9 \u00e0 conduire un v\u00e9hicule ou \u00e0 op\u00e9rer de la machinerie<\/li>\n<\/ul>\n<p>Je m\u2019engage \u00e0 ne pas conduire ni op\u00e9rer d\u2019\u00e9quipement lourd lorsque je suis sous l\u2019effet du cannabis.<\/p>\n<hr>\n<h2>4. Grossesse et sant\u00e9 mentale<\/h2>\n<p>Je reconnais que :<\/p>\n<ul>\n<li>L\u2019utilisation du cannabis pendant la grossesse ou l\u2019allaitement peut comporter des risques.<\/li>\n<li>Les personnes ayant des ant\u00e9c\u00e9dents personnels ou familiaux de psychose, de schizophr\u00e9nie ou de troubles psychiatriques graves peuvent pr\u00e9senter un risque accru.<\/li>\n<\/ul>\n<p>Je confirme avoir divulgu\u00e9 tout ant\u00e9c\u00e9dent pertinent.<\/p>\n<hr>\n<h2>5. Possession, entreposage et responsabilit\u00e9 l\u00e9gale<\/h2>\n<p>Je comprends que :<\/p>\n<ul>\n<li>Le cannabis m\u00e9dical doit \u00eatre conserv\u00e9 de fa\u00e7on s\u00e9curitaire et hors de la port\u00e9e des enfants.<\/li>\n<li>Je suis l\u00e9galement responsable de toute quantit\u00e9 autoris\u00e9e en mon nom.<\/li>\n<li>La diversion (vente, don ou distribution \u00e0 autrui) est ill\u00e9gale et peut entra\u00eener des cons\u00e9quences p\u00e9nales ainsi que la r\u00e9vocation de mon autorisation.<\/li>\n<\/ul>\n<hr>\n<h2>6. Production personnelle (si applicable)<\/h2>\n<p>Si je suis autoris\u00e9 \u00e0 cultiver du cannabis \u00e0 des fins m\u00e9dicales :<\/p>\n<ul>\n<li>Je m\u2019engage \u00e0 respecter toutes les lois f\u00e9d\u00e9rales et provinciales applicables.<\/li>\n<li>Je comprends que je ne dois pas d\u00e9passer le nombre de plants autoris\u00e9.<\/li>\n<li>Je comprends que toute production non conforme peut entra\u00eener des cons\u00e9quences l\u00e9gales.<\/li>\n<\/ul>\n<hr>\n<h2>7. Absence de garantie de r\u00e9sultat<\/h2>\n<p>Je comprends que :<\/p>\n<ul>\n<li>Le cannabis m\u00e9dical peut ne pas soulager mes sympt\u00f4mes.<\/li>\n<li>Les effets varient d\u2019une personne \u00e0 l\u2019autre.<\/li>\n<li>Des suivis m\u00e9dicaux peuvent \u00eatre requis.<\/li>\n<\/ul>\n<hr>\n<h2>8. Confidentialit\u00e9 et protection des renseignements personnels<\/h2>\n<p>Je comprends que :<\/p>\n<ul>\n<li>Mes renseignements m\u00e9dicaux seront trait\u00e9s conform\u00e9ment aux lois applicables en mati\u00e8re de protection des renseignements personnels (ex. : LPRPDE au f\u00e9d\u00e9ral et lois provinciales au Qu\u00e9bec).<\/li>\n<li>Mes informations peuvent \u00eatre transmises \u00e0 des producteurs autoris\u00e9s ou aux autorit\u00e9s comp\u00e9tentes si requis par la loi.<\/li>\n<li>Mes donn\u00e9es peuvent \u00eatre conserv\u00e9es sous forme \u00e9lectronique.<\/li>\n<\/ul>\n<hr>\n<h2>9. Honoraires et politique de remboursement<\/h2>\n<p>Je comprends que :<\/p>\n<ul>\n<li>Les frais exig\u00e9s couvrent le service d\u2019\u00e9valuation professionnelle.<\/li>\n<li>Les frais peuvent \u00eatre non remboursables une fois l\u2019\u00e9valuation compl\u00e9t\u00e9e, ind\u00e9pendamment du r\u00e9sultat.<\/li>\n<\/ul>\n<hr>\n<h2>10. Consentement libre et \u00e9clair\u00e9<\/h2>\n<p>En signant ci-dessous, je confirme que :<\/p>\n<ul>\n<li>J\u2019ai lu et compris les pr\u00e9sentes conditions g\u00e9n\u00e9rales.<\/li>\n<li>J\u2019ai eu l\u2019occasion de poser mes questions.<\/li>\n<li>Je consens librement et volontairement \u00e0 l\u2019\u00e9valuation pour cannabis m\u00e9dical.<\/li>\n<\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a1c812f0a8f3-label\"><label id=\"forminator-field-checkbox-1-1-6a1c812f0a8f3-label\" for=\"forminator-field-checkbox-1-1-6a1c812f0a8f3\" class=\"forminator-checkbox\" title=\"J\u2019ai lu et j\u2019accepte les conditions *\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6a1c812f0a8f3\" aria-labelledby=\"forminator-field-checkbox-1-1-6a1c812f0a8f3-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">J\u2019ai lu et j\u2019accepte les conditions *<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1201--page-4\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1201--page-4-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"4\"\r\n\t\t\t\tdata-label=\"4) Conditions &amp; consentement\"\r\n\t\t\t\tdata-actual-label=\"5) Signature et Pi\u00e8ce d&#039;identit\u00e9\"\r\n\t\t\t\tdata-name=\"\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">5) Signature &amp; Pi\u00e8ce d&#039;identit\u00e9<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-1\" class=\"forminator-field-signature forminator-col forminator-col-12\"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a1c812f0f23a\" id=\"forminator-field-ctlSignature6a1c812f0f23a-label\" class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a1c812f0f23a_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Apposer votre signature ici.<\/span><div id=\"ctlSignature6a1c812f0f23a_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a1c812f0f23a\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-1\" value=\"6a1c812f0f23a\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a1c812f0a8f3\" id=\"forminator-field-upload-1_6a1c812f0a8f3-label\" class=\"forminator-label\">T\u00e9l\u00e9verser une pi\u00e8ce d\u2019identit\u00e9 <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-multi-upload\" data-element=\"upload-1_6a1c812f0a8f3\"><input type=\"file\" name=\"upload-1[]\" id=\"forminator-field-upload-1_6a1c812f0a8f3\" class=\"forminator-input-file-required do-validate forminator-field-upload-1_6a1c812f0a8f3-1201\" multiple=\"multiple\" data-method=\"ajax\" data-limit=\"5\" data-limit-message=\"You can upload a maximum of 5 files.\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-1_6a1c812f0a8f3\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-1_6a1c812f0a8f3\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\" style=\"margin: 0;\"><div id=\"captcha-1\" class=\"forminator-field-captcha  forminator-col-12\"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"bottomright\" data-sitekey=\"6LcRg2ssAAAAAExTOkrveaYzEwEQOKcTIS3zehQO\" data-size=\"invisible\"><\/div> <\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled><span class=\"forminator-button--mask\" aria-label=\"hidden\"><\/span><span class=\"forminator-button--text\">Soumettre<\/span><\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"b50a1373a6\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/1110\" \/><input type=\"hidden\" name=\"form_id\" value=\"1201\"><input type=\"hidden\" name=\"page_id\" value=\"0\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"forminator-multifile-hidden\" class=\"forminator-multifile-hidden\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><label for=\"input_32\" class=\"forminator-hidden\" aria-hidden=\"true\">Please do not fill in this field. <input id=\"input_32\" type=\"text\" name=\"input_32\" value=\"\" autocomplete=\"off\"><\/label><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form><\/div><\/div><\/div><\/div><\/div><div id=\"pg-1110-2\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-1110-2-0\"  class=\"panel-grid-cell\" ><div id=\"panel-1110-2-0-0\" class=\"widget_text so-panel widget widget_custom_html panel-first-child panel-last-child\" data-index=\"2\" ><div class=\"widget_text medical_form_en panel-widget-style panel-widget-style-for-1110-2-0-0\" ><div class=\"textwidget custom-html-widget\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1204 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1204\" data-uid=\"6a1c812f17d0b\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-1204\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1204 forminator-design--material  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"1204\"\r\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"default\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6a1c812f17d0b\" action=\"\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1204--page-0\"\r\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1204--page-0-label\"\r\n\t\t\t\tdata-step=\"0\"\r\n\t\t\t\tdata-label=\"5) Signature\"\r\n\t\t\t\tdata-actual-label=\"1) Personal information\"\r\n\t\t\t\tdata-name=\"page-break-1\"\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">1) Personal information<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a1c812f17d0b\" id=\"forminator-field-name-1_6a1c812f17d0b-label\" class=\"forminator-label\">Full legal name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a1c812f17d0b\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-form-1204__field--select-1_6a1c812f17d0b\" id=\"forminator-form-1204__field--select-1_6a1c812f17d0b-label\" class=\"forminator-label\">Gender <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-1204__field--select-1_6a1c812f17d0b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select your gender\" data-search=\"false\" data-search-placeholder=\"Select your gender\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1204__field--select-1_6a1c812f17d0b-label\"><option value=\"\"  >Select your gender<\/option><option value=\"one\"  data-calculation=\"0\">Man<\/option><option value=\"two\"  data-calculation=\"0\">Woman<\/option><option value=\"Non-binaire\"  data-calculation=\"0\">Non-binary<\/option><option value=\"Pr\u00e9f\u00e8re-ne-pas-r\u00e9pondre\"  data-calculation=\"0\">I prefer not to say<\/option><\/select><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a1c812f17d0b\" id=\"forminator-field-date-1-picker_6a1c812f17d0b-label\" class=\"forminator-label\">Date of birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Chose a date\" id=\"forminator-field-date-1-picker_6a1c812f17d0b\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"yy-mm-dd\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a1c812f17d0b\" id=\"forminator-field-email-1_6a1c812f17d0b-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a1c812f17d0b\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a1c812f17d0b\" id=\"forminator-field-phone-1_6a1c812f17d0b-label\" class=\"forminator-label\">Phone number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a1c812f17d0b\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a1c812f17d0b\" id=\"forminator-field-address-1-street_address_6a1c812f17d0b-label\" class=\"forminator-label\">Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a1c812f17d0b\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a1c812f17d0b\" id=\"forminator-field-address-1-address_line_6a1c812f17d0b-label\" class=\"forminator-label\">Apartement, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a1c812f17d0b\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6a1c812f17d0b\" id=\"forminator-field-address-1-city_6a1c812f17d0b-label\" class=\"forminator-label\">City <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a1c812f17d0b\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6a1c812f17d0b\" id=\"forminator-field-address-1-state_6a1c812f17d0b-label\" class=\"forminator-label\">Province <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a1c812f17d0b\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a1c812f17d0b\" id=\"forminator-field-address-1-zip_6a1c812f17d0b-label\" class=\"forminator-label\">Postal code <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a1c812f17d0b\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-10-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-10-6a1c812f17d0b-label\" class=\"forminator-label\">Are you a Veteran, RCMP or Police officer ? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-10\" value=\"N-A\" id=\"forminator-field-radio-10-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Veteran\"><input type=\"radio\" name=\"radio-10\" value=\"one\" id=\"forminator-field-radio-10-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Veteran<\/span><\/label><label id=\"forminator-field-radio-10-label-3\" for=\"forminator-field-radio-10-3-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"RCMP\"><input type=\"radio\" name=\"radio-10\" value=\"two\" id=\"forminator-field-radio-10-3-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-10-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">RCMP<\/span><\/label><label id=\"forminator-field-radio-10-label-4\" for=\"forminator-field-radio-10-4-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Police officer\"><input type=\"radio\" name=\"radio-10\" value=\"Police-officer\" id=\"forminator-field-radio-10-4-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-10-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Police officer<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a1c812f17d0b\" id=\"forminator-field-text-2_6a1c812f17d0b-label\" class=\"forminator-label\">Referral code<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a1c812f17d0b\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-1204__field--select-3_6a1c812f17d0b\" id=\"forminator-form-1204__field--select-3_6a1c812f17d0b-label\" class=\"forminator-label\">How did you hear about us?<\/label><select  id=\"forminator-form-1204__field--select-3_6a1c812f17d0b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please choose an option\" data-search=\"false\" data-search-placeholder=\"Please choose an option\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1204__field--select-3_6a1c812f17d0b-label\"><option value=\"\"  >Please choose an option<\/option><option value=\"one\"  data-calculation=\"0\">Search engine (Google \/ Bing \/ Etc)<\/option><option value=\"two\"  data-calculation=\"0\">Social media (Facebook \/ Instagram \/ TikTok)<\/option><option value=\"Recommendation-(friend---client)\"  data-calculation=\"0\">Recommendation (friend \/ client)<\/option><option value=\"Already-a-customer\"  data-calculation=\"0\">Already a customer<\/option><option value=\"Advertisement\"  data-calculation=\"0\">Advertisement<\/option><option value=\"custom_option\"  data-calculation=\"0\">Other<\/option><\/select><div class=\"forminator-field forminator-custom-input\"><input id=\"custom-forminator-form-1204__field--select-3_6a1c812f17d0b\" name=\"custom-select-3\" class=\"forminator-input\" aria-label=\"Other\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1204--page-1\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1204--page-1-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"1\"\r\n\t\t\t\tdata-label=\"1) Personal information\"\r\n\t\t\t\tdata-actual-label=\"2) Medical history\"\r\n\t\t\t\tdata-name=\"page-break-4\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">2) Medical history<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a1c812f17d0b\" id=\"forminator-field-textarea-1_6a1c812f17d0b-label\" class=\"forminator-label\">List all previous or current medical condition<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a1c812f17d0b\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a1c812f17d0b\" id=\"forminator-field-textarea-2_6a1c812f17d0b-label\" class=\"forminator-label\">Are you taking any medications? (Is so, please list all.)<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a1c812f17d0b\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-9-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-9-6a1c812f17d0b-label\" class=\"forminator-label\">Do you have any Allergies? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-9\" value=\"one\" id=\"forminator-field-radio-9-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-9\" value=\"two\" id=\"forminator-field-radio-9-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a1c812f17d0b\" id=\"forminator-field-text-1_6a1c812f17d0b-label\" class=\"forminator-label\">Allergies<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a1c812f17d0b\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-1-6a1c812f17d0b-label\" class=\"forminator-label\">Any history of schizophrenia? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-2-6a1c812f17d0b-label\" class=\"forminator-label\">Are you pregnant \/ breastfeeding? Or planning to get pregnant soon? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-2-label-3\" for=\"forminator-field-radio-2-3-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"N\/A\"><input type=\"radio\" name=\"radio-2\" value=\"N-A\" id=\"forminator-field-radio-2-3-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-2-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">N\/A<\/span><\/label><\/div><\/div><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-3-6a1c812f17d0b-label\" class=\"forminator-label\">Any heart disease? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-4-6a1c812f17d0b-label\" class=\"forminator-label\">Any lung disease? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-5-6a1c812f17d0b-label\" class=\"forminator-label\">Any criminal history related to drug use \/ drug diversion? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-2_6a1c812f17d0b\" id=\"forminator-field-upload-2_6a1c812f17d0b-label\" class=\"forminator-label\">Medical records (\u26a0\ufe0f Optional, but greatly speeds up the process.)<\/label><span id=\"forminator-field-upload-2_6a1c812f17d0b-description\" class=\"forminator-description\">Medication History | Medical File | Previous Medical Cannabis Prescription | ACMPR Production Permit | Medicine Container (Photo)<\/span><div class=\"forminator-multi-upload\" data-element=\"upload-2_6a1c812f17d0b\" aria-describedby=\"forminator-field-upload-2_6a1c812f17d0b-description\"><input type=\"file\" name=\"upload-2[]\" id=\"forminator-field-upload-2_6a1c812f17d0b\" class=\"forminator-input-file forminator-field-upload-2_6a1c812f17d0b-1204\" multiple=\"multiple\" data-method=\"ajax\" accept=\".jpg,.jpeg,.jpe,.png,.webp,.avif,.heic,.heif,.heics,.heifs,.pdf\" data-size=\"3000000\" data-size-message=\"Maximum file size allowed is 3 MB. \" data-filetype=\"jpg|jpeg|jpe|png|webp|avif|heic|heif|heics|heifs|pdf\" data-filetype-message=\"file extension is not allowed.\"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-2_6a1c812f17d0b\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-2_6a1c812f17d0b\"><\/ul><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1204--page-2\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1204--page-2-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"2\"\r\n\t\t\t\tdata-label=\"2) Medical history\"\r\n\t\t\t\tdata-actual-label=\"3) Cannabis \u2013 Experience &amp; Goals\"\r\n\t\t\t\tdata-name=\"page-break-2\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">3) Cannabis \u2013 Experience &amp; Goals<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-6-6a1c812f17d0b-label\" class=\"forminator-label\">Have you tried cannabis? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-7-6a1c812f17d0b-label\" class=\"forminator-label\">Have you had a prescription \/ authorization to cannabis for medical reasons in the past?<\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_6a1c812f17d0b\" id=\"forminator-field-number-1_6a1c812f17d0b-label\" class=\"forminator-label\">Years of use (if applicable)<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_6a1c812f17d0b\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a1c812f17d0b\" id=\"forminator-field-textarea-3_6a1c812f17d0b-label\" class=\"forminator-label\">What do you hope to treat with cannabis? <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a1c812f17d0b\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6a1c812f17d0b\" id=\"forminator-field-textarea-4_6a1c812f17d0b-label\" class=\"forminator-label\">What have you tried in the past for these medical conditions? Please list all. (medications, therapy, massage, exercise\u2026) <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6a1c812f17d0b\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_6a1c812f17d0b\" id=\"forminator-field-textarea-5_6a1c812f17d0b-label\" class=\"forminator-label\">If you plan to grow cannabis for medical reasons, please explain what you plan to make or do with your cannabis plants? (oils, edibles, concentrates, topicals)<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_6a1c812f17d0b\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-6\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-8-6a1c812f17d0b-label\"><span id=\"forminator-radiogroup-radio-8-6a1c812f17d0b-label\" class=\"forminator-label\">Do you currently use cannabis? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"Yes\"><input type=\"radio\" name=\"radio-8\" value=\"one\" id=\"forminator-field-radio-8-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-6a1c812f17d0b\" class=\"forminator-radio forminator-radio-inline\" title=\"No\"><input type=\"radio\" name=\"radio-8\" value=\"two\" id=\"forminator-field-radio-8-2-6a1c812f17d0b\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-form-1204__field--select-2_6a1c812f17d0b\" id=\"forminator-form-1204__field--select-2_6a1c812f17d0b-label\" class=\"forminator-label\">Grams required (estimation)<\/label><select  id=\"forminator-form-1204__field--select-2_6a1c812f17d0b\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"one\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-1204__field--select-2_6a1c812f17d0b-label\"><option value=\"one\" selected=\"selected\" data-calculation=\"0\">5 Grams<\/option><option value=\"two\"  data-calculation=\"0\">10 Grams<\/option><option value=\"5-Grams\"  data-calculation=\"0\">15 Grams<\/option><option value=\"5-Grams\"  data-calculation=\"0\">20 Grams<\/option><option value=\"25-Grams\"  data-calculation=\"0\">25 Grams<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6a1c812f17d0b\" id=\"forminator-field-textarea-6_6a1c812f17d0b-label\" class=\"forminator-label\">If you require more than 5g\/day of cannabis, please explain why you require so much?<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_6a1c812f17d0b\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1204--page-3\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1204--page-3-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"3\"\r\n\t\t\t\tdata-label=\"3) Cannabis \u2013 Experience &amp; Goals\"\r\n\t\t\t\tdata-actual-label=\"4) Terms and consent\"\r\n\t\t\t\tdata-name=\"page-break-3\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">4) Terms and consent<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12\"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><h2>1. Nature of Service<\/h2>\n<p>I understand that this assessment is conducted for the purpose of evaluating my eligibility for medical cannabis authorization under applicable Canadian regulations.<\/p>\n<p>I acknowledge that:<\/p>\n<ul>\n<li>The practitioner is assessing my medical condition based on the information I provide.<\/li>\n<li>Authorization is not guaranteed.<\/li>\n<li>The practitioner may refuse authorization if deemed medically inappropriate.<\/li>\n<\/ul>\n<hr>\n<h2>2. Accuracy of Information<\/h2>\n<p>I confirm that:<\/p>\n<ul>\n<li>All information provided in this form is true, complete, and accurate.<\/li>\n<li>I have disclosed all relevant medical history, medications, and psychiatric history.<\/li>\n<li>Providing false or misleading information may result in refusal or cancellation of authorization.<\/li>\n<\/ul>\n<hr>\n<h2>3. Medical Risks &amp; Side Effects<\/h2>\n<p>I understand that medical cannabis may cause:<\/p>\n<ul>\n<li>Drowsiness<\/li>\n<li>Impaired coordination and judgment<\/li>\n<li>Anxiety or paranoia<\/li>\n<li>Increased heart rate<\/li>\n<li>Respiratory irritation (if inhaled)<\/li>\n<\/ul>\n<p>I understand that cannabis may:<\/p>\n<ul>\n<li>Interact with other medications<\/li>\n<li>Worsen certain psychiatric or cardiovascular conditions<\/li>\n<li>Impair my ability to drive or operate machinery<\/li>\n<\/ul>\n<p>I agree not to drive or operate heavy equipment while impaired.<\/p>\n<hr>\n<h2>4. Pregnancy &amp; Mental Health<\/h2>\n<p>I acknowledge that:<\/p>\n<ul>\n<li>Cannabis use during pregnancy or breastfeeding may pose risks.<\/li>\n<li>Individuals with a personal or family history of psychosis, schizophrenia, or severe psychiatric disorders may be at increased risk.<\/li>\n<\/ul>\n<p>I confirm I have disclosed any relevant history.<\/p>\n<hr>\n<h2>5. Possession, Storage &amp; Legal Responsibility<\/h2>\n<p>I understand that:<\/p>\n<ul>\n<li>Medical cannabis must be stored securely and kept away from children.<\/li>\n<li>I am legally responsible for any cannabis authorized under my name.<\/li>\n<li>Diversion (selling or giving cannabis to others) is illegal and may result in legal consequences and revocation of authorization.<\/li>\n<\/ul>\n<hr>\n<h2>6. Cultivation (If Applicable)<\/h2>\n<p>If authorized for personal production:<\/p>\n<ul>\n<li>I agree to comply with all federal and provincial regulations.<\/li>\n<li>I understand plant limits must not be exceeded.<\/li>\n<li>I understand that improper cultivation may result in legal consequences.<\/li>\n<\/ul>\n<hr>\n<h2>7. No Guarantee of Outcome<\/h2>\n<p>I understand that:<\/p>\n<ul>\n<li>Cannabis may not relieve my symptoms.<\/li>\n<li>Results vary between individuals.<\/li>\n<li>Follow-up assessments may be required.<\/li>\n<\/ul>\n<hr>\n<h2>8. Privacy &amp; Confidentiality<\/h2>\n<p>I understand that:<\/p>\n<ul>\n<li>My medical information will be handled in accordance with applicable privacy laws (e.g., PIPEDA and provincial legislation).<\/li>\n<li>My information may be shared with licensed producers or relevant authorities as required by law.<\/li>\n<li>Records may be stored electronically.<\/li>\n<\/ul>\n<hr>\n<h2>9. Fees &amp; Refund Policy<\/h2>\n<p>I understand that:<\/p>\n<ul>\n<li>Assessment fees are for professional evaluation services.<\/li>\n<li>Fees may be non-refundable once the assessment has been completed, regardless of authorization outcome.<\/li>\n<\/ul>\n<hr>\n<h2>10. Voluntary Consent<\/h2>\n<p>By signing below, I confirm that:<\/p>\n<ul>\n<li>I have read and understood these Terms and Conditions.<\/li>\n<li>I have had the opportunity to ask questions.<\/li>\n<li>I voluntarily consent to medical cannabis assessment.<\/li>\n<\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a1c812f17d0b-label\"><label id=\"forminator-field-checkbox-1-1-6a1c812f17d0b-label\" for=\"forminator-field-checkbox-1-1-6a1c812f17d0b\" class=\"forminator-checkbox\" title=\"I have read and agree to the terms and conditions *\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6a1c812f17d0b\" aria-labelledby=\"forminator-field-checkbox-1-1-6a1c812f17d0b-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I have read and agree to the terms and conditions *<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-1204--page-4\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-1204--page-4-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"4\"\r\n\t\t\t\tdata-label=\"4) Terms and consent\"\r\n\t\t\t\tdata-actual-label=\"5) Signature\"\r\n\t\t\t\tdata-name=\"\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">5) Signature &amp; ID<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-1\" class=\"forminator-field-signature forminator-col forminator-col-12\"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a1c812f1c74a\" id=\"forminator-field-ctlSignature6a1c812f1c74a-label\" class=\"forminator-label\">Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a1c812f1c74a_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a1c812f1c74a_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a1c812f1c74a\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-1\" value=\"6a1c812f1c74a\" class=\"signature-prefix\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a1c812f17d0b\" id=\"forminator-field-upload-1_6a1c812f17d0b-label\" class=\"forminator-label\">Upload a valid form of identification <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-multi-upload\" data-element=\"upload-1_6a1c812f17d0b\"><input type=\"file\" name=\"upload-1[]\" id=\"forminator-field-upload-1_6a1c812f17d0b\" class=\"forminator-input-file-required do-validate forminator-field-upload-1_6a1c812f17d0b-1204\" multiple=\"multiple\" data-method=\"ajax\" data-limit=\"5\" data-limit-message=\"You can upload a maximum of 5 files.\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-1_6a1c812f17d0b\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-1_6a1c812f17d0b\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\" style=\"margin: 0;\"><div id=\"captcha-1\" class=\"forminator-field-captcha  forminator-col-12\"><div class=\"forminator-captcha-left forminator-g-recaptcha recaptcha-invisible\" data-theme=\"light\" data-badge=\"bottomright\" data-sitekey=\"6LcRg2ssAAAAAExTOkrveaYzEwEQOKcTIS3zehQO\" data-size=\"invisible\"><\/div> <\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled><span class=\"forminator-button--mask\" aria-label=\"hidden\"><\/span><span class=\"forminator-button--text\">Submit<\/span><\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"8228ab318c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/1110\" \/><input type=\"hidden\" name=\"form_id\" value=\"1204\"><input type=\"hidden\" name=\"page_id\" value=\"0\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"forminator-multifile-hidden\" class=\"forminator-multifile-hidden\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><label for=\"input_32\" class=\"forminator-hidden\" aria-hidden=\"true\">Please do not fill in this field. <input id=\"input_32\" type=\"text\" name=\"input_32\" value=\"\" autocomplete=\"off\"><\/label><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form><\/div><\/div><\/div><\/div><\/div><div id=\"pg-1110-3\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-1110-3-0\"  class=\"panel-grid-cell\" ><div id=\"panel-1110-3-0-0\" class=\"widget_text so-panel widget widget_custom_html panel-first-child panel-last-child\" data-index=\"3\" ><div class=\"textwidget custom-html-widget\"><script>\n(function () {\n  function toggleMedicalForms() {\n    var path = window.location.pathname || \"\";\n    var isEN = \/^\\\/en(\\\/|$)\/i.test(path);\n\n    var frForms = document.querySelectorAll('.medical_form_fr');\n    var enForms = document.querySelectorAll('.medical_form_en');\n\n    frForms.forEach(function (el) { el.style.display = isEN ? 'none' : ''; });\n    enForms.forEach(function (el) { el.style.display = isEN ? '' : 'none'; });\n  }\n\n  \/\/ 1) au chargement\n  if (document.readyState === \"loading\") {\n    document.addEventListener(\"DOMContentLoaded\", toggleMedicalForms);\n  } else {\n    toggleMedicalForms();\n  }\n\n  \/\/ 2) si TranslatePress change le contenu sans recharger (selon config)\n  window.addEventListener(\"popstate\", toggleMedicalForms);\n})();\n<\/script><\/div><\/div><\/div><\/div><div id=\"pg-1110-4\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-1110-4-0\"  class=\"panel-grid-cell\" ><div id=\"panel-1110-4-0-0\" class=\"widget_text so-panel widget widget_custom_html panel-first-child\" data-index=\"4\" ><div class=\"textwidget custom-html-widget\"><div class=\"separator-line\"><\/div>\n\n<style>\n.separator-line{\n  width:100%;\n  height:2px;\n  background:#ddd;\n  margin:40px 0; \/* espace haut et bas *\/\n}\n<\/style><\/div><\/div><div id=\"panel-1110-4-0-1\" class=\"so-panel widget widget_text\" data-index=\"5\" ><h3 class=\"widget-title\"><span class=\"widget-title__inline\">(Optional)<\/span><\/h3>\t\t\t<div class=\"textwidget\"><p>For those who prefer to complete the form by hand, please print and fill out the document below, then return it to us below.&lt;<\/p>\n<p><strong data-start=\"206\" data-end=\"247\">Word form (English only): <\/strong>\u00a0<a href=\"https:\/\/crcquebec.com\/wp-content\/uploads\/MEDICAL-CANNABIS-ASSESSEMENT.docx\" download=\"MEDICAL-CANNABIS-ASSESSEMENT.docx\">MEDICAL-CANNABIS-ASSESSEMENT.docx<\/a><\/p>\n<\/div>\n\t\t<\/div><div id=\"panel-1110-4-0-2\" class=\"widget_text so-panel widget widget_custom_html panel-last-child\" data-index=\"6\" ><div class=\"textwidget custom-html-widget\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1370 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1370\" data-uid=\"6a1c812f24f37\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-1370\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1370 forminator-design--default  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"1370\"\r\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"theme\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6a1c812f24f37\" action=\"\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a1c812f24f37\" id=\"forminator-field-name-1_6a1c812f24f37-label\" class=\"forminator-label\">Full legal name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a1c812f24f37\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a1c812f24f37\" id=\"forminator-field-email-1_6a1c812f24f37-label\" class=\"forminator-label\">Email address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a1c812f24f37\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a1c812f24f37\" id=\"forminator-field-upload-1_6a1c812f24f37-label\" class=\"forminator-label\">Word form <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload\" data-element=\"upload-1_6a1c812f24f37\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_6a1c812f24f37\" class=\"forminator-input-file-required do-validate\" accept=\".avif,.heif,.heics,.heifs,.docx,.pdf,.doc,.pages,.docm,.dotx,.dotm,.odf,.xps,.wri\" tabindex=\"-1\"><button id=\"forminator-field-upload-1_6a1c812f24f37_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_6a1c812f24f37\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-upload-2_6a1c812f24f37\" id=\"forminator-field-upload-2_6a1c812f24f37-label\" class=\"forminator-label\">Valid ID (front\/back) <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-multi-upload\" data-element=\"upload-2_6a1c812f24f37\"><input type=\"file\" name=\"upload-2[]\" id=\"forminator-field-upload-2_6a1c812f24f37\" class=\"forminator-input-file-required do-validate forminator-field-upload-2_6a1c812f24f37-1370\" multiple=\"multiple\" data-method=\"ajax\" accept=\".jpg,.jpeg,.jpe,.png,.webp,.avif,.heic,.heif,.heics,.heifs\" data-limit=\"2\" data-limit-message=\"You can upload a maximum of 2 files.\" data-size=\"2000000\" data-size-message=\"Maximum file size allowed is 2 MB. \" data-filetype=\"jpg|jpeg|jpe|png|webp|avif|heic|heif|heics|heifs\" data-filetype-message=\"file extension is not allowed.\"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-2_6a1c812f24f37\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-2_6a1c812f24f37\"><\/ul><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Send<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"ff63334966\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/1110\" \/><input type=\"hidden\" name=\"form_id\" value=\"1370\"><input type=\"hidden\" name=\"page_id\" value=\"0\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"forminator-multifile-hidden\" class=\"forminator-multifile-hidden\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form><\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Formulaire de consentement m\u00e9dical 1) Informations personnellesNom l\u00e9gal complet *Genre *S\u00e9lectionner votre genreFemmeHommeNon-binairePr\u00e9f\u00e8re ne pas r\u00e9pondreDate de naissance *Adresse courriel *T\u00e9l\u00e9phone *Adresse *Appartement, suite, etcVille *Province *Code postal *\u00cates-vous un ancien combattant, un agent de la GRC ou un policier ? *NonAncien combattantAgent de la GRCPolicierComment avez-vous entendu parler de nous ?Veuillez choisirMoteur de recherche 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