{"id":18,"date":"2021-05-11T13:09:24","date_gmt":"2021-05-11T13:09:24","guid":{"rendered":"http:\/\/imm-mg.com\/?page_id=18"},"modified":"2023-07-18T10:18:50","modified_gmt":"2023-07-18T10:18:50","slug":"reservation-old","status":"publish","type":"page","link":"https:\/\/imm-mg.com\/en\/reservation-old\/","title":{"rendered":"R\u00e9servation Old"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00a0\u00bb1&Prime; _builder_version=\u00a0\u00bb4.9.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb][et_pb_row _builder_version=\u00a0\u00bb4.9.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb][et_pb_column type=\u00a0\u00bb4_4&Prime; _builder_version=\u00a0\u00bb4.9.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb][et_pb_code _builder_version=\u00a0\u00bb4.9.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb]<!-- Note :<!-- [et_pb_line_break_holder] -->   &#8211; You can modify the font style and form style to suit your website. <!-- [et_pb_line_break_holder] --> 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action='https:\/\/crm.zoho.com\/crm\/WebForm' name=\"WebForm4504418000006948774\" method='POST' enctype='multipart\/form-data' onsubmit='javascript:document.charset=\"UTF-8\"; return checkMandatory4504418000006948774()' accept-charset='UTF-8' data-trp-original-action=\"https:\/\/crm.zoho.com\/crm\/WebForm\"><!-- [et_pb_line_break_holder] --> <input type='text' style='display:none;' name='xnQsjsdp' value='b86a05eb5380d3bcafb9b181dc8b9248902ed49eeb743757d123b0b4ae2becc3'><\/input> <!-- [et_pb_line_break_holder] --> <input type='hidden' name='zc_gad' id='zc_gad' value=''><\/input> <!-- [et_pb_line_break_holder] --> <input type='text' style='display:none;' name='xmIwtLD' value='ed6d88b4a0efc81c0ae9332c3535c8b4ef411b6fecfd19a0d390cda5362b4a8f'><\/input> <!-- [et_pb_line_break_holder] --> <input type='text'  style='display:none;' name='actionType' value='Q3VzdG9tTW9kdWxlOA=='><\/input><!-- [et_pb_line_break_holder] --><input type='text' style='display:none;' name='returnURL' value='https:\/\/imm-mg.com\/5926-2\/' > <\/input><!-- [et_pb_line_break_holder] --> <link rel=\"stylesheet\" href=\"https:\/\/stackpath.bootstrapcdn.com\/bootstrap\/4.3.1\/css\/bootstrap.min.css\" integrity=\"sha384-ggOyR0iXCbMQv3Xipma34MD+dH\/1fQ784\/j6cY\/iJTQUOhcWr7x9JvoRxT2MZw1T\" crossorigin=\"anonymous\"><!-- [et_pb_line_break_holder] -->\t <!-- Do not remove this code. --><!-- [et_pb_line_break_holder] --><\/p>\n<style><!-- [et_pb_line_break_holder] -->html,body{<!-- [et_pb_line_break_holder] -->\tmargin: 0px;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->#crmWebToEntityForm.zcwf_lblLeft {<!-- [et_pb_line_break_holder] -->\twidth:100%;<!-- [et_pb_line_break_holder] -->\tpadding: 25px;<!-- [et_pb_line_break_holder] -->\tmargin: 0 auto;<!-- [et_pb_line_break_holder] -->\tbox-sizing: border-box;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->#crmWebToEntityForm.zcwf_lblLeft * {<!-- [et_pb_line_break_holder] -->\tbox-sizing: border-box;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->#crmWebToEntityForm{text-align: left;}<!-- [et_pb_line_break_holder] -->#crmWebToEntityForm * {<!-- [et_pb_line_break_holder] -->\tdirection: ltr;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_title {<!-- [et_pb_line_break_holder] -->\tword-wrap: break-word;<!-- [et_pb_line_break_holder] -->\tpadding: 0px 6px 10px;<!-- [et_pb_line_break_holder] -->\tfont-weight: bold;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_col_fld input[type=text], .zcwf_lblLeft .zcwf_col_fld textarea {<!-- [et_pb_line_break_holder] -->\twidth: 60%;<!-- [et_pb_line_break_holder] -->\tborder: 1px solid #ccc !important;<!-- [et_pb_line_break_holder] -->\tresize: vertical;<!-- [et_pb_line_break_holder] -->\tborder-radius: 2px;<!-- [et_pb_line_break_holder] -->\tfloat: left;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft 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-->\tmax-width: 35%;<!-- [et_pb_line_break_holder] -->\tword-break: break-word;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_help_icon {<!-- [et_pb_line_break_holder] -->\tcursor: pointer;<!-- [et_pb_line_break_holder] -->\twidth: 16px;<!-- [et_pb_line_break_holder] -->\theight: 16px;<!-- [et_pb_line_break_holder] -->\tdisplay: inline-block;<!-- [et_pb_line_break_holder] -->\tbackground: #fff;<!-- [et_pb_line_break_holder] -->\tborder: 1px solid #ccc;<!-- [et_pb_line_break_holder] -->\tcolor: #ccc;<!-- [et_pb_line_break_holder] -->\ttext-align: center;<!-- [et_pb_line_break_holder] -->\tfont-size: 11px;<!-- [et_pb_line_break_holder] -->\tline-height: 16px;<!-- [et_pb_line_break_holder] -->\tfont-weight: bold;<!-- [et_pb_line_break_holder] -->\tborder-radius: 50%;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_row {margin: 15px 0px;}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .formsubmit {<!-- 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[et_pb_line_break_holder] -->\tpadding: 3px 9px;<!-- [et_pb_line_break_holder] -->\tborder-radius: 4px;<!-- [et_pb_line_break_holder] -->\tcursor: pointer;<!-- [et_pb_line_break_holder] -->\tmax-width: 120px;<!-- [et_pb_line_break_holder] -->\toverflow: hidden;<!-- [et_pb_line_break_holder] -->\ttext-overflow: ellipsis;<!-- [et_pb_line_break_holder] -->\twhite-space: nowrap;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_tooltip_over{<!-- [et_pb_line_break_holder] -->\tposition: relative;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_tooltip_ctn{<!-- [et_pb_line_break_holder] -->\tposition: absolute;<!-- [et_pb_line_break_holder] -->\tbackground: #dedede;<!-- [et_pb_line_break_holder] -->\tpadding: 3px 6px;<!-- [et_pb_line_break_holder] -->\ttop: 3px;<!-- [et_pb_line_break_holder] -->\tborder-radius: 4px;word-break: break-all;<!-- [et_pb_line_break_holder] -->\tmin-width: 50px;<!-- [et_pb_line_break_holder] -->\tmax-width: 150px;<!-- [et_pb_line_break_holder] -->\tcolor: #333;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_ckbox{<!-- [et_pb_line_break_holder] -->\tfloat: left;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.zcwf_lblLeft .zcwf_file{<!-- [et_pb_line_break_holder] -->\twidth: 55%;<!-- [et_pb_line_break_holder] -->\tbox-sizing: border-box;<!-- [et_pb_line_break_holder] -->\tfloat: left;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->.clearB:after{<!-- [et_pb_line_break_holder] -->\tcontent:'';<!-- [et_pb_line_break_holder] -->\tdisplay: block;<!-- [et_pb_line_break_holder] -->\tclear: both;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->@media all and (max-width: 900px) {<!-- [et_pb_line_break_holder] -->\t.zcwf_lblLeft .zcwf_col_lab, .zcwf_lblLeft .zcwf_col_fld {<!-- [et_pb_line_break_holder] -->\t\twidth: auto;<!-- [et_pb_line_break_holder] -->\t\tfloat: none !important;<!-- [et_pb_line_break_holder] -->\t}<!-- [et_pb_line_break_holder] -->\t.zcwf_lblLeft .zcwf_col_help {width: 40%;}<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] --><\/style>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"alert alert-primary\" role=\"alert\"><!-- [et_pb_line_break_holder] -->  Please note that your appointment can only be taken after a precise indication of the date and time of reservation as well as the reception of the payment by mobile money (MVola or Orange Money). <!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"alert alert-success\" role=\"alert\"><!-- [et_pb_line_break_holder] -->  In case of reservation, our team will contact you to inform you about the availability of places in our time slot and the rate for the requested service.<!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"alert alert-danger\" role=\"alert\"><!-- [et_pb_line_break_holder] -->  If you need to cancel or postpone an appointment, please inform us at least 3 hours in advance via our call center at 032 23 217 17 by typing 3<!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"alert alert-dark\" role=\"alert\"><!-- [et_pb_line_break_holder] --> If you do not show up at the indicated time within 15 minutes, we invite you to renew your request by calling our switchboard 032 23 217 17.<!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class='form-group row'><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF17'>Type<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-4\"><!-- [et_pb_line_break_holder] -->\t\t<select class=\"custom-select\" id='COBJ8CF17' name='COBJ8CF17'  ><!-- [et_pb_line_break_holder] --><option value='-None-'>-None-<\/option><!-- [et_pb_line_break_holder] --><option value='Pr\u00e9-r\u00e9servation'>Pr\u00e9-r\u00e9servation<\/option><!-- [et_pb_line_break_holder] --><option value='R\u00e9servation'>Reservation<\/option><!-- [et_pb_line_break_holder] -->\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class='form-group row'><!-- [et_pb_line_break_holder] -->\t<label  class=\"col-sm-2 col-form-label\" for='COBJ8CF1'>Name<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-10\"><!-- [et_pb_line_break_holder] -->\t\t<input type='text' class=\"form-control\" id='COBJ8CF1' name='COBJ8CF1' maxlength='255'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class='form-group row'><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF81'>Date of birth<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-4\"><!-- [et_pb_line_break_holder] -->\t\t<input type='text' class=\"form-control\" id='COBJ8CF81' name='COBJ8CF81' maxlength='20' ftype='date' placeholder='DD\/MM\/YYYY' tplid='4504418000006948774COBJ8CF81' onfocus='formCalender.stEv(event);formCalender.createCalendar(this);' autocomplete='off'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div id='template4504418000006948774COBJ8CF81'  onclick='formCalender.stEv(event);'  class='tempCalDiv'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF9'>Sex<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-4\"><!-- [et_pb_line_break_holder] -->\t\t<select class=\"custom-select\" id='COBJ8CF9' name='COBJ8CF9'  ><!-- [et_pb_line_break_holder] --><option value='-None-'>-None-<\/option><!-- [et_pb_line_break_holder] --><option value='m'>Male<\/option><!-- [et_pb_line_break_holder] --><option value='f'>Female<\/option><!-- [et_pb_line_break_holder] -->\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class='form-group row'><!-- [et_pb_line_break_holder] -->        <label class=\"col-sm-2 col-form-label\" for='COBJ8CF51'>Weight<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='col-sm-2'><!-- [et_pb_line_break_holder] -->\t\t<input type='text' class=\"form-control\" id='COBJ8CF51' name='COBJ8CF51' maxlength='9' placeholder=\"in Kg\"><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF10'>Address<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-10\"><!-- [et_pb_line_break_holder] -->\t\t<input class=\"form-control\" type='text' id='COBJ8CF10' name='COBJ8CF10' maxlength='255'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF5'>Contact<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-4\"><!-- [et_pb_line_break_holder] -->\t\t<input class=\"form-control\" type='text' id='COBJ8CF5' name='COBJ8CF5' maxlength='30'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='Email'>Mail<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-4\"><!-- [et_pb_line_break_holder] -->\t\t<input class=\"form-control\" type='text' ftype='email' id='Email' name='Email' maxlength='100'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF2'>Attending physician<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-10\"><!-- [et_pb_line_break_holder] -->\t\t<input class=\"form-control\" type='text' id='COBJ8CF2' name='COBJ8CF2' maxlength='255'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF4'>Contact of attending physician<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-4\"><!-- [et_pb_line_break_holder] -->\t\t<input class=\"form-control\" type='text' id='COBJ8CF4' name='COBJ8CF4' maxlength='30'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF6'>Your physical examination<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-4\"><!-- [et_pb_line_break_holder] -->\t\t<select class=\"custom-select\" id='COBJ8CF6' name='COBJ8CF6' multiple><!-- [et_pb_line_break_holder] --><option value='ANALYSE'>ANALYSIS<\/option><!-- [et_pb_line_break_holder] --><option value='AUTRES'>OTHER<\/option><!-- [et_pb_line_break_holder] --><option value='ECG'>ECG<\/option><!-- [et_pb_line_break_holder] --><option value='ECHOGRAPHIE'>ULTRASOUND<\/option><!-- [et_pb_line_break_holder] --><option value='ENDOSCOPIE'>ENDOSCOPY<\/option><!-- [et_pb_line_break_holder] --><option value='MAMMOGRAPHIE'>MAMMOGRAPHY<\/option><!-- [et_pb_line_break_holder] --><option value='RADIOGRAPHIE'>X-RAYS<\/option><!-- [et_pb_line_break_holder] --><option value='CONSULTATION'>CONSULTATION<\/option><!-- [et_pb_line_break_holder] --><option value='EXAMENS SPECIAUX'>EXAMENS SPECIAUX<\/option><!-- [et_pb_line_break_holder] --><option value='SCANNER'>CT-Scan<\/option><!-- [et_pb_line_break_holder] -->\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF117'>Date et heure demand\u00e9e<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"form-row col-sm-8\"><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class=\"col\"><!-- [et_pb_line_break_holder] -->\t\t\t<input class=\"form-control\" type='text' id='COBJ8CF117' name='COBJ8CF117' maxlength='120' ftype='date' placeholder='DD\/MM\/YYYY' tplid='4504418000006948774COBJ8CF117' onfocus='formCalender.stEv(event);formCalender.createCalendar(this);' autocomplete='off'><\/input><!-- [et_pb_line_break_holder] -->\t\t\t<\/p>\n<div id='template4504418000006948774COBJ8CF117' onclick='formCalender.stEv(event);'  class='tempCalDiv'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t\t<\/div>\n<p><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class=\"col\"><!-- [et_pb_line_break_holder] -->\t\t\t<select class=\"custom-select\" name='COBJ8CF117hour'><!-- [et_pb_line_break_holder] --><option value='01'>01<\/option><!-- [et_pb_line_break_holder] --><option value='02'>02<\/option><!-- [et_pb_line_break_holder] --><option value='03'>03<\/option><!-- [et_pb_line_break_holder] --><option value='04'>04<\/option><!-- [et_pb_line_break_holder] --><option value='05'>05<\/option><!-- [et_pb_line_break_holder] --><option value='06'>06<\/option><!-- [et_pb_line_break_holder] --><option value='07'>07<\/option><!-- [et_pb_line_break_holder] --><option value='08'>08<\/option><!-- [et_pb_line_break_holder] --><option value='09'>09<\/option><!-- [et_pb_line_break_holder] --><option value='10'>10<\/option><!-- [et_pb_line_break_holder] --><option value='11'>11<\/option><!-- [et_pb_line_break_holder] --><option value='12'>12<\/option><!-- [et_pb_line_break_holder] -->\t\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/div>\n<p><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class=\"col\"><!-- [et_pb_line_break_holder] -->\t\t\t<select class=\"custom-select\" name='COBJ8CF117minute'><!-- [et_pb_line_break_holder] --><option value='00'>00<\/option><!-- [et_pb_line_break_holder] --><option value='01'>01<\/option><!-- [et_pb_line_break_holder] --><option value='02'>02<\/option><!-- [et_pb_line_break_holder] --><option value='03'>03<\/option><!-- [et_pb_line_break_holder] --><option value='04'>04<\/option><!-- [et_pb_line_break_holder] --><option value='05'>05<\/option><!-- [et_pb_line_break_holder] --><option value='06'>06<\/option><!-- [et_pb_line_break_holder] --><option value='07'>07<\/option><!-- [et_pb_line_break_holder] --><option value='08'>08<\/option><!-- [et_pb_line_break_holder] --><option value='09'>09<\/option><!-- [et_pb_line_break_holder] --><option value='10'>10<\/option><!-- [et_pb_line_break_holder] --><option value='11'>11<\/option><!-- [et_pb_line_break_holder] --><option value='12'>12<\/option><!-- [et_pb_line_break_holder] --><option value='13'>13<\/option><!-- [et_pb_line_break_holder] --><option value='14'>14<\/option><!-- [et_pb_line_break_holder] --><option value='15'>15<\/option><!-- [et_pb_line_break_holder] --><option value='16'>16<\/option><!-- [et_pb_line_break_holder] --><option value='17'>17<\/option><!-- [et_pb_line_break_holder] --><option value='18'>18<\/option><!-- [et_pb_line_break_holder] --><option value='19'>19<\/option><!-- [et_pb_line_break_holder] --><option value='20'>20<\/option><!-- [et_pb_line_break_holder] --><option value='21'>21<\/option><!-- [et_pb_line_break_holder] --><option value='22'>22<\/option><!-- [et_pb_line_break_holder] --><option value='23'>23<\/option><!-- [et_pb_line_break_holder] --><option value='24'>24<\/option><!-- [et_pb_line_break_holder] --><option value='25'>25<\/option><!-- [et_pb_line_break_holder] --><option value='26'>26<\/option><!-- [et_pb_line_break_holder] --><option value='27'>27<\/option><!-- [et_pb_line_break_holder] --><option value='28'>28<\/option><!-- [et_pb_line_break_holder] --><option value='29'>29<\/option><!-- [et_pb_line_break_holder] --><option value='30'>30<\/option><!-- [et_pb_line_break_holder] --><option value='31'>31<\/option><!-- [et_pb_line_break_holder] --><option value='32'>32<\/option><!-- [et_pb_line_break_holder] --><option value='33'>33<\/option><!-- [et_pb_line_break_holder] --><option value='34'>34<\/option><!-- [et_pb_line_break_holder] --><option value='35'>35<\/option><!-- [et_pb_line_break_holder] --><option value='36'>36<\/option><!-- [et_pb_line_break_holder] --><option value='37'>37<\/option><!-- [et_pb_line_break_holder] --><option value='38'>38<\/option><!-- [et_pb_line_break_holder] --><option value='39'>39<\/option><!-- [et_pb_line_break_holder] --><option value='40'>40<\/option><!-- [et_pb_line_break_holder] --><option value='41'>41<\/option><!-- [et_pb_line_break_holder] --><option value='42'>42<\/option><!-- [et_pb_line_break_holder] --><option value='43'>43<\/option><!-- [et_pb_line_break_holder] --><option value='44'>44<\/option><!-- [et_pb_line_break_holder] --><option value='45'>45<\/option><!-- [et_pb_line_break_holder] --><option value='46'>46<\/option><!-- [et_pb_line_break_holder] --><option value='47'>47<\/option><!-- [et_pb_line_break_holder] --><option value='48'>48<\/option><!-- [et_pb_line_break_holder] --><option value='49'>49<\/option><!-- [et_pb_line_break_holder] --><option value='50'>50<\/option><!-- [et_pb_line_break_holder] --><option value='51'>51<\/option><!-- [et_pb_line_break_holder] --><option value='52'>52<\/option><!-- [et_pb_line_break_holder] --><option value='53'>53<\/option><!-- [et_pb_line_break_holder] --><option value='54'>54<\/option><!-- [et_pb_line_break_holder] --><option value='55'>55<\/option><!-- [et_pb_line_break_holder] --><option value='56'>56<\/option><!-- [et_pb_line_break_holder] --><option value='57'>57<\/option><!-- [et_pb_line_break_holder] --><option value='58'>58<\/option><!-- [et_pb_line_break_holder] --><option value='59'>59<\/option><!-- [et_pb_line_break_holder] -->\t\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/div>\n<p><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class=\"col\"><!-- [et_pb_line_break_holder] -->\t\t\t<select class=\"custom-select\" name='COBJ8CF117ampm'><!-- [et_pb_line_break_holder] --><option value='AM'>AM<\/option><!-- [et_pb_line_break_holder] --><option value='PM'>PM<\/option><!-- [et_pb_line_break_holder] -->\t\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<!--\/div--><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><pee><!-- [et_pb_line_break_holder] -->  Etes-vous:<!-- [et_pb_line_break_holder] --><\/pee><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"custom-control custom-checkbox custom-control-inline\"><!-- [et_pb_line_break_holder] -->\t<input class=\"custom-control-input\" type='checkbox' id='COBJ8CF103' name='COBJ8CF103' maxlength='3'><\/input><!-- [et_pb_line_break_holder] -->\t<label class=\"custom-control-label\" for='COBJ8CF103'>Diabetes<\/label>\t<!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"custom-control custom-checkbox custom-control-inline\"><!-- [et_pb_line_break_holder] -->\t<input class=\"custom-control-input\" type='checkbox' id='COBJ8CF104' name='COBJ8CF104' maxlength='3'><\/input><!-- [et_pb_line_break_holder] -->\t<label class=\"custom-control-label\" for='COBJ8CF104'>HTA<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"custom-control custom-checkbox custom-control-inline\"><!-- [et_pb_line_break_holder] -->\t<input class=\"custom-control-input\" type='checkbox' id='COBJ8CF105' name='COBJ8CF105' maxlength='3'><\/input><!-- [et_pb_line_break_holder] -->\t<label class=\"custom-control-label\" for='COBJ8CF105'>Seafood allergy<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"custom-control custom-checkbox custom-control-inline\"><!-- [et_pb_line_break_holder] -->\t<input class=\"custom-control-input\" type='checkbox' id='COBJ8CF102' name='COBJ8CF102' maxlength='3'><\/input><!-- [et_pb_line_break_holder] -->\t<label class=\"custom-control-label\" for='COBJ8CF102'>Pregnancy<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"custom-control custom-checkbox custom-control-inline\"><!-- [et_pb_line_break_holder] -->\t<input class=\"custom-control-input\" type='checkbox' id='COBJ8CF106' name='COBJ8CF106' maxlength='3'><\/input><!-- [et_pb_line_break_holder] -->\t<label class=\"custom-control-label\" for='COBJ8CF106'>Asthma<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"custom-control custom-checkbox custom-control-inline\"><!-- [et_pb_line_break_holder] -->\t<input class=\"custom-control-input\" type='checkbox' id='COBJ8CF101' name='COBJ8CF101' maxlength='2'><\/input><!-- [et_pb_line_break_holder] -->\t<label class=\"custom-control-label\" for='COBJ8CF101'>R\u00e9sultat cr\u00e9atininemie<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><!--div class='form-group row'><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF52'>Creatinine level<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-2\"><!-- [et_pb_line_break_holder] -->\t\t<input type='text' class=\"form-control\" id='COBJ8CF52' name='COBJ8CF52' maxlength='9' placeholder=\"in \u00b5mol\/L\"><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div--><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF7'>Reason review<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-10\"><!-- [et_pb_line_break_holder] -->\t\t<input class=\"form-control\" type='text' id='COBJ8CF7' name='COBJ8CF7' maxlength='255'><\/input><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF11'>Current medication (medication)<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-10\"><!-- [et_pb_line_break_holder] -->\t\t<textarea class=\"form-control\" id='COBJ8CF11' name='COBJ8CF11'><\/textarea><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF12'>Payment method<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-2\"><!-- [et_pb_line_break_holder] -->\t\t<select class=\"custom-select\" id='COBJ8CF12' name='COBJ8CF12'  ><!-- [et_pb_line_break_holder] --><option value='-None-'>-None-<\/option><!-- [et_pb_line_break_holder] --><option value='Mvola'>Mvola<\/option><!-- [et_pb_line_break_holder] --><option value='Esp\u00e8ce'>Esp\u00e8ce<\/option><!-- [et_pb_line_break_holder] --><option value='Ch\u00e8que'>Ch\u00e8que<\/option><!-- [et_pb_line_break_holder] -->\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\" for='COBJ8CF13'>Health Coverage<span style='color:red;'>*<\/span><\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-2\"><!-- [et_pb_line_break_holder] -->\t\t<select class=\"custom-select\" id='COBJ8CF13' name='COBJ8CF13'  ><!-- [et_pb_line_break_holder] --><option value='-None-'>-None-<\/option><!-- [et_pb_line_break_holder] --><option value='Fonctionnaire'>Fonctionnaire<\/option><!-- [et_pb_line_break_holder] --><option value='Priv\u00e9e'>Priv\u00e9e<\/option><!-- [et_pb_line_break_holder] --><option value='Autres'>Autres<\/option><!-- [et_pb_line_break_holder] -->\t\t<\/select><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<label class=\"col-sm-2 col-form-label\">T\u00e9l\u00e9charger l&rsquo;ordonnance<\/label><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-10\"><!-- [et_pb_line_break_holder] -->\t\t<input type='file' class=\"form-control-file\" name='theFile' id='theFile4504418000006948774' multiple \/><!-- [et_pb_line_break_holder] -->\t\t<\/p>\n<div class='zcwf_col_help'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t\t<pee style='color:black;font-size:11px;padding-left:3px;'>Max upload limit is 20Mo<\/pee><!-- [et_pb_line_break_holder] -->\t<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"form-group row\"><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class=\"col-sm-2 col-form-label\" style='font-size:16px; font-family: Arial;'>Enter captcha<\/div>\n<p><!-- [et_pb_line_break_holder] -->\t <\/p>\n<div class='zcwf_col_fld'><input class=\"form-control\" type='text' maxlength='10' name='enterdigest' \/><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] -->\t <\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<!-- Do not remove this code. --><!-- [et_pb_line_break_holder] -->\t    <\/p>\n<div class='zcwf_row'>\n<div class='zcwf_col_lab'><\/div>\n<div class='zcwf_col_fld'><img id='imgid4504418000006948774' src='https:\/\/crm.zoho.com\/crm\/CaptchaServlet?formId=ed6d88b4a0efc81c0ae9332c3535c8b4ef411b6fecfd19a0d390cda5362b4a8f&#038;grpid=b86a05eb5380d3bcafb9b181dc8b9248902ed49eeb743757d123b0b4ae2becc3'><!-- [et_pb_line_break_holder] -->\t    <a href='javascript:;' onclick='reloadImg4504418000006948774();'>Reload<\/a><\/div>\n<div class=''><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/div>\n<div class='zcwf_row'>\n<div class='zcwf_privacy'>\n<div class='dIB vat' align='left'>\n<div class='displayPurpose  f13'><label class='newCustomchkbox-md dIB w100per'><input autocomplete='off' id='privacyTool4504418000006948774' type='checkbox' name='privacyTool' onclick='disableErr4504418000006948774()'><\/label><\/div>\n<\/div>\n<div class='dIB zcwf_privacy_txt' style='font-size: 16px;font-family:Arial;color: black;'>I agree to the Privacy Policy and Terms of Service.<\/div>\n<div  id='privacyErr4504418000006948774' style='font-size:12px;color:red;padding-left: 5px;visibility:hidden;'>Veuillez accepter ce<\/div>\n<\/div>\n<\/div>\n<div class='zcwf_row'>\n<div class='zcwf_col_lab'><\/div>\n<p><!-- [et_pb_line_break_holder] -->\t<\/p>\n<div class='zcwf_col_fld'><!-- [et_pb_line_break_holder] -->\t\t<input type='submit' id='formsubmit' class=\"btn btn-outline-primary btn-lg\" value='Submit' title='Submit'><!-- [et_pb_line_break_holder] -->\t\t<input type='reset' class=\"btn btn-outline-info btn-lg\" value='Reset' title='Reset'><\/div>\n<\/div>\n<p>[\/et_pb_code][et_pb_code _builder_version=\u00a0\u00bb4.9.4&Prime; _module_preset=\u00a0\u00bbdefault\u00a0\u00bb]<script src=\"https:\/\/code.jquery.com\/jquery-3.3.1.slim.min.js\" integrity=\"sha384-q8i\/X+965DzO0rT7abK41JStQIAqVgRVzpbzo5smXKp4YfRvH+8abtTE1Pi6jizo\" crossorigin=\"anonymous\"><\/script><!-- [et_pb_line_break_holder] --><script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/popper.js\/1.14.7\/umd\/popper.min.js\" integrity=\"sha384-UO2eT0CpHqdSJQ6hJty5KVphtPhzWj9WO1clHTMGa3JDZwrnQq4sF86dIHNDz0W1\" crossorigin=\"anonymous\"><\/script><!-- [et_pb_line_break_holder] --><script src=\"https:\/\/stackpath.bootstrapcdn.com\/bootstrap\/4.3.1\/js\/bootstrap.min.js\" integrity=\"sha384-JjSmVgyd0p3pXB1rRibZUAYoIIy6OrQ6VrjIEaFf\/nJGzIxFDsf4x0xIM+B07jRM\" crossorigin=\"anonymous\"><\/script><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><script type='text\/javascript'><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] -->var formCalender={userPattern:'YYYY-MM-DD',currDateObj:void 0,currMonth:void 0,currYear:void 0,currDate:void 0,currMonthEnd:[31,28,31,30,31,30,31,31,30,31,30,31],monthName:void 0,days:void 0,displayPanel:void 0,isHideToday:void 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