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    {"id":1735,"date":"2024-08-01T10:59:58","date_gmt":"2024-08-01T14:59:58","guid":{"rendered":"https:\/\/gynovie.ca\/patient-portal\/"},"modified":"2024-08-26T21:28:05","modified_gmt":"2024-08-27T01:28:05","slug":"patient-portal","status":"publish","type":"page","link":"https:\/\/gynovie.ca\/en\/patient-portal\/","title":{"rendered":"Patient portal"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:right top;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:128px;--awb-padding-right:100px;--awb-padding-bottom:120px;--awb-padding-left:100px;--awb-padding-right-medium:70px;--awb-padding-left-medium:70px;--awb-padding-top-small:0px;--awb-padding-right-small:20px;--awb-padding-bottom-small:120px;--awb-padding-left-small:20px;--awb-margin-bottom-small:0px;--awb-background-color:#ffffff;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:0%;--awb-spacing-left-small:0%;\" data-scroll-devices=\"small-visibility,medium-visibility,large-visibility\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><p style=\"text-align: center;\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework form_step_nt_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_13' style='display:none'><div id='gf_13' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_13' id='gform_13' class='form_step_nt' action='\/en\/wp-json\/wp\/v2\/pages\/1735#gf_13' data-formid='13' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LetzE4nAAAAAO_1XzcwPpBb4i8SdUpPbOcCSlqC' data-tabindex='0'><input id=\"input_2581bcd571aec2f3f1c41c4964174506\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_2581bcd571aec2f3f1c41c4964174506\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_13_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_200\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full htblc gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1 class=\"rdvtit\" style=\"color: #5ac6cc; font-size:55px; font-family: OVERPASS !important; font-weight: 900 !important;\">PATIENT PORTAL<\/h1>\n<p style=\"margin-top: -25px; font-size:26px;\">This space is reserved for patients. Schedule or cancel an appointment, or leave a message for your doctor with just a few clicks.<\/p><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_1'>Start<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_2' class='gform_page' data-js='page-field-id-70' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full maintit gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >You are a patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_61'>\n\t\t\t<div class='gchoice gchoice_13_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Obstetrics : Pregnant'  id='choice_13_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_61_0' id='label_13_61_0' class='gform-field-label gform-field-label--type-inline'>Obstetrics : Pregnant<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Gynecology: You are not pregnant but have just given birth or wish to access gynecological services.'  id='choice_13_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_61_1' id='label_13_61_1' class='gform-field-label gform-field-label--type-inline'>Gynecology: You are not pregnant but have just given birth or wish to access gynecological services.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='You wish to cancel an appointment already booked at our clinic'  id='choice_13_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_61_2' id='label_13_61_2' class='gform-field-label gform-field-label--type-inline'>You wish to cancel an appointment already booked at our clinic<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_61_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='You would like to leave a message for your doctor or ask him\/her a question'  id='choice_13_61_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_61_3' id='label_13_61_3' class='gform-field-label gform-field-label--type-inline'>You would like to leave a message for your doctor or ask him\/her a question<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_2'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_3' class='gform_page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full maintit gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >I am pregnant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_62'>\n\t\t\t<div class='gchoice gchoice_13_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='New pregnancy : you wish to book your first pregnancy appointment'  id='choice_13_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_62_0' id='label_13_62_0' class='gform-field-label gform-field-label--type-inline'>New pregnancy : you wish to book your first pregnancy appointment<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Pregnancy follow-up: You&#039;ve already had your first pregnancy appointment with one of our obstetrician-gynecologists, but you need further assistance.'  id='choice_13_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_62_1' id='label_13_62_1' class='gform-field-label gform-field-label--type-inline'>Pregnancy follow-up: You've already had your first pregnancy appointment with one of our obstetrician-gynecologists, but you need further assistance.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_72' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_3'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_4' class='gform_page' data-js='page-field-id-72' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full maintit gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gynecology<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_63'>\n\t\t\t<div class='gchoice gchoice_13_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='You have an active file at GynOvie (Is your file still active? To find out, consult our FAQ, section &#039;gynecology&#039;'  id='choice_13_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_0' id='label_13_63_0' class='gform-field-label gform-field-label--type-inline'>You have an active file at GynOvie (Is your file still active? To find out, consult our FAQ, section 'gynecology'<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='You do not have a file at the clinic, but a doctor has sent you a referral for a gynecological consultation.'  id='choice_13_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_63_1' id='label_13_63_1' class='gform-field-label gform-field-label--type-inline'>You do not have a file at the clinic, but a doctor has sent you a referral for a gynecological consultation.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_73' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_4'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_5' class='gform_page' data-js='page-field-id-73' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full maintit gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Origin of the request for consultation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_13_64'>\n\t\t\t<div class='gchoice gchoice_13_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='The referral is from a family doctor'  id='choice_13_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_64_0' id='label_13_64_0' class='gform-field-label gform-field-label--type-inline'>The referral is from a family doctor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_13_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='The referral is from a medical specialist'  id='choice_13_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_13_64_1' id='label_13_64_1' class='gform-field-label gform-field-label--type-inline'>The referral is from a medical specialist<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_9' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_5'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_6' class='gform_page' data-js='page-field-id-9' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection deux-lignes field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PATIENT FORM - APPOINTMENT CANCELLATION<\/h3><\/div><div id=\"field_13_102\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please note : any appointment not cancelled within the previous 48 business hours will incur a $40 fee which must be paid in cash before any other appointment can be booked.  \n  \n<br\/>Please note that your request will be processed within 2 business days.<\/div><div id=\"field_13_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_14'>Full name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_13_14' type='text' value='' class='large'    placeholder='Full name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_147\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_147'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_147' id='input_13_147' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of birth*' aria-describedby=\"input_13_147_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_147_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_147' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_3\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_3'>Phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_13_3' type='tel' value='' class='large'  placeholder='Phone number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_4\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >E-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_13_4_container'>\n                                <span id='input_13_4_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4' id='input_13_4' value=''   placeholder='Enter your email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_4' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_13_4_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_4_2' id='input_13_4_2' value=''   placeholder='Confirm email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_4_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_13_20\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_20'>Reason for cancellation (20 words)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_13_20' class='textarea small'   maxlength='200' placeholder='Reason for cancellation (20 words)*' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_21\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Would you like to book another appointment at the clinic ? If so, a new appointment request will be sent to you via e-mail.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_87' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_6'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_7' class='gform_page' data-js='page-field-id-87' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_88\" class=\"gfield gfield--type-section gfield--input-type-section gsection deux-lignes field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PATIENT FORM - QUESTION OR MESSAGE FOR THE DOCTOR<\/h3><\/div><div id=\"field_13_99\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Complete this section only if you do not need to be assessed by your doctor. Please make an appointment if you wish to be assessed by your gynecologist.\n<br\/>Gynecologists' schedules are split between hospital activities (operating days, 24-hour on-call duty) and outpatient clinics (colposcopy and ultrasound clinics, Gynovie). Your doctor doesn't come to Gynovie every day. It may therefore take several business days before we can answer your question or forward your message to your doctor. \n<br\/>Please note that an appointment is necessary if you develop new symptoms or if your condition does not improve. For emergencies, please go to the nearest emergency room, or visit a walk-in clinic. Please note that we do not provide acute care at the clinic, nor do we have a walk-in clinic.\n<br\/><br\/>\nYour message will be processed within 7 business days.<\/div><div id=\"field_13_89\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_89'>Full name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_13_89' type='text' value='' class='large'    placeholder='Full name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_148\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_148'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_148' id='input_13_148' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of birth*' aria-describedby=\"input_13_148_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_148_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_148' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_91\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_91'>Telephone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_91' id='input_13_91' type='tel' value='' class='large'  placeholder='Telephone number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_92\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >E-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_13_92_container'>\n                                <span id='input_13_92_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_92' id='input_13_92' value=''   placeholder='Enter your email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_92' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_13_92_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_92_2' id='input_13_92_2' value=''   placeholder='Confirm email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_92_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_13_93\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_93'>Please ask your question or leave your message here (40 words)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_93' id='input_13_93' class='textarea small'   maxlength='400' placeholder='Please ask your question or leave your message here (40 words)*' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_7'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_8' class='gform_page' data-js='page-field-id-45' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection deux-lignes field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PREGNANCY FOLLOW-UP<\/h3><\/div><div id=\"field_13_96\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If you are 20 weeks pregnant or more and are experiencing vaginal bleeding, contractions, abdominal pain, fluid loss, decreased fetal movements or any other worrisome symptoms, please contact the Centre M\u00e8re-Enfant at Suro\u00eet Hospital at 450-371-9920, ext. 2146. If you are less than 20 weeks pregnant, please go to the nearest emergency room. Please note that we do not provide acute care at the clinic, nor do we have a walk-in clinic.\n<br\/><br\/>\nPlease note that your request will be processed within three business days.\n<br\/><br\/>\nTo help us process your request, please take a few minutes to complete our questionnaire. Please specify the purpose of your request so that we can serve you better.<\/div><div id=\"field_13_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_47'>Last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_13_47' type='text' value='' class='large'    placeholder='Last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_145\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_145'>First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_13_145' type='text' value='' class='large'    placeholder='First name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_146\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_146'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_146' id='input_13_146' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of birth*' aria-describedby=\"input_13_146_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_146_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_146' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_48\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_48'>Phone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_48' id='input_13_48' type='tel' value='' class='large'  placeholder='Phone number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_49\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >E-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_13_49_container'>\n                                <span id='input_13_49_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_49' id='input_13_49' value=''   placeholder='Enter your email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_49' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_13_49_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_49_2' id='input_13_49_2' value=''   placeholder='Confirm email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_49_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_13_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_50'>Reason for your request (100 words)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_13_50' class='textarea small'   maxlength='1000' placeholder='Reason for your request (100 words)*' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_38' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_8'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_9' class='gform_page' data-js='page-field-id-38' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_54\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">NEW PATIENT - FAMILY MD<\/h3><\/div><div id=\"field_13_98\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Your family doctor must forward the consultation referral to the Centre de R\u00e9partition des Demandes de Services (CRDS). This is the access point set up by the Quebec Ministry of Health and Social Services to help patients who need a first appointment with a specialist. \n<br\/>\nYour consultation referral is prioritized by the CRDS, based on information provided by your family doctor. The CRDS team will make the appointment and contact you. \n<br\/>\nOur clinic is subject to the same CRDS requirements and regulations as other specialist clinics. We have no control over the prioritization of requests or wait times. The granting of appointments is beyond our control. Please contact your family physician if your health status changes while you are on the waitlist.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_53' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_9'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_10' class='gform_page' data-js='page-field-id-53' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\">NEW PREGNANCY<\/h3><\/div><div id=\"field_13_204\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"stepcount\" style=\"text-align: center; font-size: 18px; font-weight: 800;\">Step 1\/3<\/p><\/div><div id=\"field_13_203\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PERSONAL INFORMATION<\/h3><\/div><div id=\"field_13_101\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >All our gynecologists are affiliated with the Suro\u00eet Hospital in Salaberry-de-Valleyfield. Please note that if you choose to be looked after at our clinic, your delivery will take place at the Suro\u00eet Hospital.\n<br\/><br\/>\nPlease note that your request will be processed within three business days.\n<br\/><br\/>\nTo simplify the process, please take a few minutes to complete our questionnaire.<\/div><div id=\"field_13_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_74'>Health insurance number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_13_74' type='text' value='' class='large'    placeholder='Health insurance number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_197\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_197'>Expiry date on your health insurance card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_197' id='input_13_197' type='text' value='' class='large'    placeholder='Expiry date on your health insurance card (mm\/yy)*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_198\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_198'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_198' id='input_13_198' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of birth*' aria-describedby=\"input_13_198_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_198_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_198' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_76'>Last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_13_76' type='text' value='' class='large'    placeholder='Last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_137\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_137'>First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_13_137' type='text' value='' class='large'    placeholder='First name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_77'>Your mother\u2019s name and maiden name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_13_77' type='text' value='' class='large'    placeholder='Your mother\u2019s name and maiden name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_183\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_183'>Your full address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_183' id='input_13_183' type='text' value='' class='large'    placeholder='Your full address*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_79\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_79'>Your telephone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_79' id='input_13_79' type='tel' value='' class='large'  placeholder='Your telephone number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_80\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your e-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_13_80_container'>\n                                <span id='input_13_80_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_80' id='input_13_80' value=''   placeholder='Enter your email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_80' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_13_80_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_80_2' id='input_13_80_2' value=''   placeholder='Confirm email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_80_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_13_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_81'>Your father&#039;s first and last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_13_81' type='text' value='' class='large'    placeholder='Your father&#039;s first and last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_82'>Your family doctor&#039;s first and last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_13_82' type='text' value='' class='large'    placeholder='Your family doctor&#039;s first and last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_84\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_84'>Your pharmacy&#039;s name and address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_13_84' type='text' value='' class='large'    placeholder='Your pharmacy&#039;s name and address*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_85\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_85'>Your spouse&#039;s first and last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_13_85' type='text' value='' class='large'    placeholder='Your spouse&#039;s first and last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_181\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_181'>Your spouse&#039;s date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_181' id='input_13_181' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Your spouse&#039;s date of birth*' aria-describedby=\"input_13_181_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_181_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_181' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_86\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_86'>Your spouse&#039;s telephone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_86' id='input_13_86' type='tel' value='' class='large'  placeholder='Your spouse&#039;s telephone number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_201' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_10'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_11' class='gform_page' data-js='page-field-id-201' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_202\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"stepcount\" style=\"text-align: center; font-size: 18px; font-weight: 800;\">Step 2\/3<\/p><\/div><div id=\"field_13_140\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_140'>First day of your last period<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_140' id='input_13_140' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='First day of your last period*' aria-describedby=\"input_13_140_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_140_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_140' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_13_158\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optlabel2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How many pregnancies have you had in the past ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_158'><div class='gchoice gchoice_13_158_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.1' type='checkbox'  value='Number of vaginal deliveries'  id='choice_13_158_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_158_1' id='label_13_158_1' class='gform-field-label gform-field-label--type-inline'>Number of vaginal deliveries<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_158_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.2' type='checkbox'  value='Number of caesarean deliveries'  id='choice_13_158_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_158_2' id='label_13_158_2' class='gform-field-label gform-field-label--type-inline'>Number of caesarean deliveries<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_158_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.3' type='checkbox'  value='Number of miscarriages'  id='choice_13_158_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_158_3' id='label_13_158_3' class='gform-field-label gform-field-label--type-inline'>Number of miscarriages<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_158_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.4' type='checkbox'  value='Number of ectopic pregnancies'  id='choice_13_158_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_158_4' id='label_13_158_4' class='gform-field-label gform-field-label--type-inline'>Number of ectopic pregnancies<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_158_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.5' type='checkbox'  value='New pregnancy'  id='choice_13_158_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_158_5' id='label_13_158_5' class='gform-field-label gform-field-label--type-inline'>New pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_139\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_150\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_150'>Number of vaginal deliveries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_13_150' type='text' value='' class='large'    placeholder='Number of vaginal deliveries*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_155\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_151\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_151'>Number of caesarean deliveries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_13_151' type='text' value='' class='large'    placeholder='Number of caesarean deliveries*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_154\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_152\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_152'>Number of miscarriages<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_13_152' type='text' value='' class='large'    placeholder='Number of miscarriages*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_156\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_153\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_153'>Number of ectopic pregnancies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_13_153' type='text' value='' class='large'    placeholder='Number of ectopic pregnancies*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_157\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_142\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_142'>Have you ever been treated by a gynecologist at the Gynovie clinic? If so, which one ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_142' id='input_13_142' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Doctor Haddad' >Doctor Haddad<\/option><option value='Doctor Lubin' >Doctor Lubin<\/option><option value='Doctor Brisson' >Doctor Brisson<\/option><option value='Doctor Roy-Morency' >Doctor Roy-Morency<\/option><option value='Doctor Afiuni' >Doctor Afiuni<\/option><option value='Doctor Tsoyem' >Doctor Tsoyem<\/option><option value='Je n&#039;ai pas encore \u00e9t\u00e9 suivi par un gyn\u00e9cologue' >Je n&#039;ai pas encore \u00e9t\u00e9 suivi par un gyn\u00e9cologue<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_205' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_11'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_12' class='gform_page' data-js='page-field-id-205' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_206\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"stepcount\" style=\"text-align: center; font-size: 18px; font-weight: 800;\">Step 3\/3<\/p><\/div><fieldset id=\"field_13_159\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optlabel2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Do you suffer from a chronic illness ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_159'><div class='gchoice gchoice_13_159_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.1' type='checkbox'  value='Heart disease'  id='choice_13_159_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_159_1' id='label_13_159_1' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_159_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.2' type='checkbox'  value='Pulmonary embolism or thrombophlebitis'  id='choice_13_159_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_159_2' id='label_13_159_2' class='gform-field-label gform-field-label--type-inline'>Pulmonary embolism or thrombophlebitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_159_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.3' type='checkbox'  value='Type 1 or 2 diabetes'  id='choice_13_159_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_159_3' id='label_13_159_3' class='gform-field-label gform-field-label--type-inline'>Type 1 or 2 diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_159_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.4' type='checkbox'  value='High blood pressure'  id='choice_13_159_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_159_4' id='label_13_159_4' class='gform-field-label gform-field-label--type-inline'>High blood pressure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_159_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.5' type='checkbox'  value='Other, please specify (20 words)'  id='choice_13_159_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_159_5' id='label_13_159_5' class='gform-field-label gform-field-label--type-inline'>Other, please specify (20 words)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_161\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_165\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_165'>Specification<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_165' id='input_13_165' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_162\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_13_160\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optlabel2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever had a pregnancy-related complication ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_160'><div class='gchoice gchoice_13_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='Premature delivery'  id='choice_13_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_160_1' id='label_13_160_1' class='gform-field-label gform-field-label--type-inline'>Premature delivery<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_160_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.2' type='checkbox'  value='Severe growth delay'  id='choice_13_160_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_160_2' id='label_13_160_2' class='gform-field-label gform-field-label--type-inline'>Severe growth delay<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_160_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.3' type='checkbox'  value='Pre-eclampsia or HELLP syndrome'  id='choice_13_160_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_160_3' id='label_13_160_3' class='gform-field-label gform-field-label--type-inline'>Pre-eclampsia or HELLP syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_160_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.4' type='checkbox'  value='Ectopic pregnancy'  id='choice_13_160_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_160_4' id='label_13_160_4' class='gform-field-label gform-field-label--type-inline'>Ectopic pregnancy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_160_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.5' type='checkbox'  value='Recurrent miscarriage'  id='choice_13_160_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_160_5' id='label_13_160_5' class='gform-field-label gform-field-label--type-inline'>Recurrent miscarriage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_160_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.6' type='checkbox'  value='Other, please specify (20 words)'  id='choice_13_160_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_160_6' id='label_13_160_6' class='gform-field-label gform-field-label--type-inline'>Other, please specify (20 words)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_163\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_166\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_166'>Specifications<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_166' id='input_13_166' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_164\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_144\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_144'>If you have a special request, please mention it here<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_144' id='input_13_144' class='textarea small'   maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_56' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_12'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_13' class='gform_page' data-js='page-field-id-56' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_59\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">GYNECOLOGICAL FOLLOW-UP<\/h3><\/div><div id=\"field_13_207\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"stepcount\" style=\"text-align: center; font-size: 18px; font-weight: 800;\">Step 1\/2<\/p><\/div><div id=\"field_13_100\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >If you are experiencing heavy bleeding (change of protection every hour for two hours in a row), acute abdominal pain, fever or any other worrisome symptom requiring immediate attention, please go to the nearest emergency room, or consult a walk-in clinic. Please note that we do not provide acute care at the clinic, nor do we have a walk-in clinic.\n<br\/><br\/>\nPlease note that your request will be processed within two business days.\n<br\/><br\/>\nTo help us process your request, please take a few minutes to complete our questionnaire.<\/div><div id=\"field_13_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_65'>Last name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_13_65' type='text' value='' class='large'    placeholder='Last name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_103\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_103'>First name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_13_103' type='text' value='' class='large'    placeholder='First name*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_13_104\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_104'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_104' id='input_13_104' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of birth*' aria-describedby=\"input_13_104_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_104_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_104' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_67\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_67'>Telephone number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_67' id='input_13_67' type='tel' value='' class='large'  placeholder='Telephone number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_13_68\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >E-mail address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_13_68_container'>\n                                <span id='input_13_68_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_68' id='input_13_68' value=''   placeholder='Enter your email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_68' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_13_68_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_68_2' id='input_13_68_2' value=''   placeholder='Confirm email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_13_68_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_208' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_13'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_14' class='gform_page' data-js='page-field-id-208' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_209\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p class=\"stepcount\" style=\"text-align: center; font-size: 18px; font-weight: 800;\">Step 2\/2<\/p><\/div><fieldset id=\"field_13_107\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reason for request<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_107'><div class='gchoice gchoice_13_107_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.1' type='checkbox'  value='Post-operative appointment'  id='choice_13_107_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_1' id='label_13_107_1' class='gform-field-label gform-field-label--type-inline'>Post-operative appointment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.2' type='checkbox'  value='Postpartum appointment'  id='choice_13_107_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_2' id='label_13_107_2' class='gform-field-label gform-field-label--type-inline'>Postpartum appointment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.3' type='checkbox'  value='Abnormal menstruation'  id='choice_13_107_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_3' id='label_13_107_3' class='gform-field-label gform-field-label--type-inline'>Abnormal menstruation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.4' type='checkbox'  value='Post-menopausal bleeding'  id='choice_13_107_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_4' id='label_13_107_4' class='gform-field-label gform-field-label--type-inline'>Post-menopausal bleeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.5' type='checkbox'  value='Menopause symptoms'  id='choice_13_107_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_5' id='label_13_107_5' class='gform-field-label gform-field-label--type-inline'>Menopause symptoms<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.6' type='checkbox'  value='Pessary maintenance'  id='choice_13_107_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_6' id='label_13_107_6' class='gform-field-label gform-field-label--type-inline'>Pessary maintenance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.7' type='checkbox'  value='Contraception'  id='choice_13_107_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_7' id='label_13_107_7' class='gform-field-label gform-field-label--type-inline'>Contraception<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.8' type='checkbox'  value='Your gynecologist follows you for a vulvar pathology and you want to make a follow-up appointment'  id='choice_13_107_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_8' id='label_13_107_8' class='gform-field-label gform-field-label--type-inline'>Your gynecologist follows you for a vulvar pathology and you want to make a follow-up appointment<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.9' type='checkbox'  value='Fertility'  id='choice_13_107_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_9' id='label_13_107_9' class='gform-field-label gform-field-label--type-inline'>Fertility<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_107_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_107.11' type='checkbox'  value='Other, please specify'  id='choice_13_107_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_107_11' id='label_13_107_11' class='gform-field-label gform-field-label--type-inline'>Other, please specify<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_178\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_130\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_130'>Name of the gynecologist who operated on you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_130' id='input_13_130' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Doctor Haddad' >Doctor Haddad<\/option><option value='Doctor Lubin' >Doctor Lubin<\/option><option value='Doctor Brisson' >Doctor Brisson<\/option><option value='Doctor Roy-Morency' >Doctor Roy-Morency<\/option><option value='Doctor Afiuni' >Doctor Afiuni<\/option><option value='Doctor Tsoyem' >Doctor Tsoyem<\/option><\/select><\/div><\/div><div id=\"field_13_179\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_131\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_131'>Date of surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_131' id='input_13_131' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_131_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_131_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_131' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_180\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_132\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_132'>Type of surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_132' id='input_13_132' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Hysterectomy (removal of the uterus)' >Hysterectomy (removal of the uterus)<\/option><option value='Hysteroscopy (uterine camera)' >Hysteroscopy (uterine camera)<\/option><option value='Endometrial ablation (endometriectomy)' >Endometrial ablation (endometriectomy)<\/option><option value='Ovariectomy (removal of ovaries)' >Ovariectomy (removal of ovaries)<\/option><option value='Curettage' >Curettage<\/option><option value='Tubal ligation (sterilization)' >Tubal ligation (sterilization)<\/option><option value='Anti-prolapse surgery (&quot;organ descent&quot;)' >Anti-prolapse surgery (&quot;organ descent&quot;)<\/option><option value='Laparoscopy for endometriosis or ovarian cysts' >Laparoscopy for endometriosis or ovarian cysts<\/option><option value='Labiaplasty minora' >Labiaplasty minora<\/option><option value='Other, please specify' >Other, please specify<\/option><\/select><\/div><\/div><div id=\"field_13_195\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_196\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_196'>Specification<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_196' id='input_13_196' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_117\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_177\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_177'>Your due date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_177' id='input_13_177' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_13_177_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_13_177_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_13_177' class='gform_hidden' value='https:\/\/gynovie.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_13_176\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_133\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_133'>Delivery type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_133' id='input_13_133' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Vaginal delivery' >Vaginal delivery<\/option><option value='Caesarean section' >Caesarean section<\/option><\/select><\/div><\/div><div id=\"field_13_175\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_189\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_189'>With the installation of an IUD<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_189' id='input_13_189' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_13_188\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_190\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_190'>With the installation of a Nexplanon contraceptive implant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_190' id='input_13_190' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_13_187\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_112'>Abnormal menstruation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_13_112' class='textarea small'   maxlength='200' placeholder='Please describe your symptoms' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_118\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_113\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_113'>Post-menopausal bleeding<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_13_113' class='textarea small'   maxlength='200' placeholder='Please describe your symptoms' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_119\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_13_120\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optlabel2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Menopause symptoms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_120'><div class='gchoice gchoice_13_120_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.1' type='checkbox'  value='Hot flashes'  id='choice_13_120_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_120_1' id='label_13_120_1' class='gform-field-label gform-field-label--type-inline'>Hot flashes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_120_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.2' type='checkbox'  value='Vaginal dryness'  id='choice_13_120_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_120_2' id='label_13_120_2' class='gform-field-label gform-field-label--type-inline'>Vaginal dryness<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_120_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_120.3' type='checkbox'  value='Other, please specify'  id='choice_13_120_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_120_3' id='label_13_120_3' class='gform-field-label gform-field-label--type-inline'>Other, please specify<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_124\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_168\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_168'>Specification<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_168' id='input_13_168' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_167\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_13_121\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optlabel2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pessary maintenance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_121'><div class='gchoice gchoice_13_121_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.1' type='checkbox'  value='Routine follow-up'  id='choice_13_121_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_121_1' id='label_13_121_1' class='gform-field-label gform-field-label--type-inline'>Routine follow-up<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_121_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.2' type='checkbox'  value='Your pessary has fallen out or doesn&#039;t fit properly'  id='choice_13_121_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_121_2' id='label_13_121_2' class='gform-field-label gform-field-label--type-inline'>Your pessary has fallen out or doesn't fit properly<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_121_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.3' type='checkbox'  value='You are bleeding'  id='choice_13_121_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_121_3' id='label_13_121_3' class='gform-field-label gform-field-label--type-inline'>You are bleeding<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_121_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.4' type='checkbox'  value='You think you have an infection'  id='choice_13_121_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_121_4' id='label_13_121_4' class='gform-field-label gform-field-label--type-inline'>You think you have an infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_121_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_121.5' type='checkbox'  value='Other, please specify'  id='choice_13_121_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_121_5' id='label_13_121_5' class='gform-field-label gform-field-label--type-inline'>Other, please specify<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_174\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_169\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_169'>Specification<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_169' id='input_13_169' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_125\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_13_122\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optlabel2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contraception<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_122'><div class='gchoice gchoice_13_122_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.1' type='checkbox'  value='Installtion of an IUD'  id='choice_13_122_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_1' id='label_13_122_1' class='gform-field-label gform-field-label--type-inline'>Installtion of an IUD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_122_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.2' type='checkbox'  value='Changing an IUD'  id='choice_13_122_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_2' id='label_13_122_2' class='gform-field-label gform-field-label--type-inline'>Changing an IUD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_122_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.3' type='checkbox'  value='Nexplanon implant installation'  id='choice_13_122_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_3' id='label_13_122_3' class='gform-field-label gform-field-label--type-inline'>Nexplanon implant installation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_122_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.4' type='checkbox'  value='Changing or removing a Nexplanon implant'  id='choice_13_122_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_4' id='label_13_122_4' class='gform-field-label gform-field-label--type-inline'>Changing or removing a Nexplanon implant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_122_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.5' type='checkbox'  value='You would like to discuss your contraceptive options'  id='choice_13_122_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_5' id='label_13_122_5' class='gform-field-label gform-field-label--type-inline'>You would like to discuss your contraceptive options<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_122_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.6' type='checkbox'  value='You would like a follow-up appointment to discuss your current contraception'  id='choice_13_122_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_6' id='label_13_122_6' class='gform-field-label gform-field-label--type-inline'>You would like a follow-up appointment to discuss your current contraception<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_122_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.7' type='checkbox'  value='You are experiencing side effects and would like to discuss them with your gynecologist, please specify'  id='choice_13_122_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_7' id='label_13_122_7' class='gform-field-label gform-field-label--type-inline'>You are experiencing side effects and would like to discuss them with your gynecologist, please specify<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_122_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_122.8' type='checkbox'  value='Other, please specify'  id='choice_13_122_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_122_8' id='label_13_122_8' class='gform-field-label gform-field-label--type-inline'>Other, please specify<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_173\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_170\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_170'>Specification<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_170' id='input_13_170' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_193\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_194\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_194'>Specification<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_194' id='input_13_194' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_126\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_13_123\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full optlabel2 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your gynecologist follows you for a vulvar pathology and you want to make a follow-up appointment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_13_123'><div class='gchoice gchoice_13_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='Lichen sclerosus follow-up'  id='choice_13_123_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_123_1' id='label_13_123_1' class='gform-field-label gform-field-label--type-inline'>Lichen sclerosus follow-up<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_123_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.2' type='checkbox'  value='Vaginitis follow-up'  id='choice_13_123_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_123_2' id='label_13_123_2' class='gform-field-label gform-field-label--type-inline'>Vaginitis follow-up<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_13_123_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.3' type='checkbox'  value='Other, please specify'  id='choice_13_123_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_13_123_3' id='label_13_123_3' class='gform-field-label gform-field-label--type-inline'>Other, please specify<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_13_172\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_171\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_171'>Specification<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_171' id='input_13_171' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_127\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_114\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_114'>Fertility<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_13_114' class='textarea small'   maxlength='200' placeholder='Please describe your situation' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_13_128\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_13_115\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full optlabel field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_13_115'>Other, please specify<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_115' id='input_13_115' class='textarea small'   maxlength='200'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_57' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_14'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_15' class='gform_page' data-js='page-field-id-57' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_13_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">NEW PATIENT - SPECIALIZED MD<\/h3><\/div><div id=\"field_13_97\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >This section applies to you if your referral has been made by a specialist and not by a family doctor. Here are some examples of specialists: gynecologists from another clinic, emergency physicians, urologists, internists, general surgeons, oncologists, etc. \n<br\/>\nThe specialist must fax your referral to the Gynovie clinic (450-859-0011). The consultation referral will be evaluated and prioritized by one of the clinic's gynecologists. Please note that we receive a high volume of requests for consultations. Wait times vary depending on the reason for the consultation. Please contact your family doctor or referring physician if your health status changes while you are on the waitlist.\n<br\/>\nWe will contact you by e-mail to arrange an appointment. Please note that you will not receive any calls to book or confirm appointments. All communication will be via e-mail.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_191' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_15'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_16' class='gform_page' data-js='page-field-id-191' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_16' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_11\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Clinic Rules<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_13_11' tabindex='0'>The gynecologists at the GynOvie clinic are affiliated with the H\u00f4pital r\u00e9gional du Suro\u00eet in Valleyfield. Therefore, your delivery or surgery will take place at the Suro\u00eet Hospital.<br \/>\n<br \/>\nYou may be accompanied by only one adult aged 18 or over during your medical visit. To avoid overcrowding in the waiting room, your accompanying adult will follow you into the examination room during your appointment.<br \/>\n<br \/>\nPlease note that all treatments offered at the clinic are covered by the RAMQ. You are required to bring proof of health insurance coverage to EACH of your medical visits (valid health insurance card or proof of insurance provided by the R\u00e9gie). Without proof of insurability, your appointment may be postponed.<br \/>\n<br \/>\nIt is important to confirm your appointment via the clinic's portal to avoid it being cancelled. Due to the high number of no-shows and despite the required e-mail confirmation, a $40 fee (cash) will be charged for appointments missed or cancelled within 48 business hours. The fee must be paid to the clinic before any other appointment is booked.<br \/>\n<br \/>\nPlease arrive at the clinic 10 minutes before your appointment time for triage and be available for the doctor at your appointment time. If you arrive 15 minutes late for your appointment, your gynecologist may not be able to see you and your appointment may be cancelled.<br \/>\n<br \/>\nIf this is a telephone consultation, the doctor will contact you. The appointment time is approximate. The number on your call display may be confidential, unknown or private.<br \/>\n<br \/>\nThe clinic is currently experiencing a major staff shortage. In order to provide you with quality service, we encourage communication via the Clinic Portal and our website. <\/div><div class='ginput_container ginput_container_consent'><input name='input_11.1' id='input_13_11_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_13_11\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_11_1' >I have read the clinic rules and I accept the conditions.<\/label><input type='hidden' name='input_11.2' value='I have read the clinic rules and I accept the conditions.' class='gform_hidden' \/><input type='hidden' name='input_11.3' value='14' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_60' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_16'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_17' class='gform_page' data-js='page-field-id-60' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_17' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_192\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Clinic rules<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_13_192' tabindex='0'>The gynecologists at the GynOvie clinic are affiliated with the H\u00f4pital r\u00e9gional du Suro\u00eet in Valleyfield. Therefore, your delivery or surgery will take place at the Suro\u00eet Hospital.<br \/>\n<br \/>\nYou may be accompanied by only one adult aged 18 or over during your medical visit. To avoid overcrowding in the waiting room, your accompanying adult will follow you into the examination room during your appointment.<br \/>\n<br \/>\nPlease note that all treatments offered at the clinic are covered by the RAMQ. You are required to bring proof of health insurance coverage to EACH of your medical visits (valid health insurance card or proof of insurance provided by the R\u00e9gie). Without proof of insurability, your appointment may be postponed.<br \/>\n<br \/>\nIt is important to confirm your appointment via the clinic's portal to avoid it being cancelled. Due to the high number of no-shows and despite the required e-mail confirmation, a $40 fee (cash) will be charged for appointments missed or cancelled within 48 business hours. The fee must be paid to the clinic before any other appointment is booked.<br \/>\n<br \/>\nPlease arrive at the clinic 10 minutes before your appointment time for triage and be available for the doctor at your appointment time. If you arrive 15 minutes late for your appointment, your gynecologist may not be able to see you and your appointment may be cancelled.<br \/>\n<br \/>\nIf this is a telephone consultation, the doctor will contact you. The appointment time is approximate. The number on your call display may be confidential, unknown or private.<br \/>\n<br \/>\nThe clinic is currently experiencing a major staff shortage. In order to provide you with quality service, we encourage communication via the Clinic Portal and our website. <\/div><div class='ginput_container ginput_container_consent'><input name='input_192.1' id='input_13_192_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_13_192\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_192_1' >I have read the clinic rules and accept the conditions.<\/label><input type='hidden' name='input_192.2' value='I have read the clinic rules and accept the conditions.' class='gform_hidden' \/><input type='hidden' name='input_192.3' value='14' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_13_94' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <button class='gform_next_button button btn_nt_next' id='gform_next_button_13_17'>Continue<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_13_18' class='gform_page' data-js='page-field-id-94' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_13_18' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_13_95\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Clinic rules<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_13_95' tabindex='0'>The gynecologists at the GynOvie clinic are affiliated with the H\u00f4pital r\u00e9gional du Suro\u00eet in Valleyfield. Therefore, your delivery or surgery will take place at the Suro\u00eet Hospital.<br \/>\n<br \/>\nYou may be accompanied by only one adult aged 18 or over during your medical visit. To avoid overcrowding in the waiting room, your accompanying adult will follow you into the examination room during your appointment.<br \/>\n<br \/>\nPlease note that all treatments offered at the clinic are covered by the RAMQ. You are required to bring proof of health insurance coverage to EACH of your medical visits (valid health insurance card or proof of insurance provided by the R\u00e9gie). Without proof of insurability, your appointment may be postponed.<br \/>\n<br \/>\nIt is important to confirm your appointment via the clinic's portal to avoid it being cancelled. Due to the high number of no-shows and despite the required e-mail confirmation, a $40 fee (cash) will be charged for appointments missed or cancelled within 48 business hours. The fee must be paid to the clinic before any other appointment is booked.<br \/>\n<br \/>\nPlease arrive at the clinic 10 minutes before your appointment time for triage and be available for the doctor at your appointment time. If you arrive 15 minutes late for your appointment, your gynecologist may not be able to see you and your appointment may be cancelled.<br \/>\n<br \/>\nIf this is a telephone consultation, the doctor will contact you. The appointment time is approximate. The number on your call display may be confidential, unknown or private.<br \/>\n<br \/>\nThe clinic is currently experiencing a major staff shortage. In order to provide you with quality service, we encourage communication via the Clinic Portal and our website. <\/div><div class='ginput_container ginput_container_consent'><input name='input_95.1' id='input_13_95_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_13_95\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_13_95_1' >I have read the clinic rules and accept the conditions.<\/label><input type='hidden' name='input_95.2' value='I have read the clinic rules and accept the conditions.' class='gform_hidden' \/><input type='hidden' name='input_95.3' value='14' class='gform_hidden' \/><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_13' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' 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