{"id":5234,"date":"2022-08-22T18:59:34","date_gmt":"2022-08-22T18:59:34","guid":{"rendered":"https:\/\/coi.iris.ca\/formulaire-de-reference"},"modified":"2025-04-11T12:02:09","modified_gmt":"2025-04-11T12:02:09","slug":"formulaire-de-reference","status":"publish","type":"page","link":"https:\/\/coi.iris.ca\/en\/formulaire-de-reference","title":{"rendered":"Formulaire de r\u00e9f\u00e9rence"},"content":{"rendered":"\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_23' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_23'  action='\/en\/wp-json\/wp\/v2\/pages\/5234' data-formid='23' >\n                        <div class='gform-body gform_body'><div id='gform_fields_23' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_23_20\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_20\"><h3 class=\"gsection_title\">MOTIF DE LA R\u00c9F\u00c9RENCE<\/h3><\/div><div id=\"field_23_260\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_260\"><p>Veuillez s\u00e9lectionner le type de consultation d\u00e9sir\u00e9e.<\/p><\/div><fieldset id=\"field_23_290\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full inline_radio field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_23_290\"><legend class='gfield_label gform-field-label'  >Motif de la r\u00e9f\u00e9rence<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_290'>\n\t\t\t<div class='gchoice gchoice_23_290_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_290' type='radio' value='CHIRURGIE R\u00c9FRACTIVE'  id='choice_23_290_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_290_0' id='label_23_290_0' class='gform-field-label gform-field-label--type-inline'>CHIRURGIE R\u00c9FRACTIVE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_290_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_290' type='radio' value='CHIRURGIE DE LA CATARACTE'  id='choice_23_290_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_290_1' id='label_23_290_1' class='gform-field-label gform-field-label--type-inline'>CHIRURGIE DE LA CATARACTE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_290_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_290' type='radio' value='NEURO-OPHTALMOLOGIE'  id='choice_23_290_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_290_2' id='label_23_290_2' class='gform-field-label gform-field-label--type-inline'>NEURO-OPHTALMOLOGIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_290_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_290' type='radio' value='OPHTALMO G\u00c9N\u00c9RALE'  id='choice_23_290_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_290_3' id='label_23_290_3' class='gform-field-label gform-field-label--type-inline'>OPHTALMO G\u00c9N\u00c9RALE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_163\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_163\"><\/div><fieldset id=\"field_23_165\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_165\"><legend class='gfield_label gform-field-label'  >Priorit\u00e9<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_165'>\n\t\t\t<div class='gchoice gchoice_23_165_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Normale (1 \u00e0 3 mois)'  id='choice_23_165_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_165_0' id='label_23_165_0' class='gform-field-label gform-field-label--type-inline'>Normale (1 \u00e0 3 mois)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_165_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Urgent'  id='choice_23_165_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_165_1' id='label_23_165_1' class='gform-field-label gform-field-label--type-inline'>Urgent<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_45\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_45\">*La COI est une clinique priv\u00e9e, non affili\u00e9e \u00e0 un h\u00f4pital. En cons\u00e9quence, certains services ne pourront \u00eatre offerts sur place. Les cas d\u2019urgence ou d\u2019infection n\u00e9cessitant une prise en charge imm\u00e9diate (moins de 4 semaines) devront \u00eatre r\u00e9f\u00e9r\u00e9s directement en centre hospitalier ou la clinique d\u2019ophtalmologie de votre choix, offrant\ndes services d\u2019urgence.<\/div><div id=\"field_23_261\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_261\">*La COI est une clinique priv\u00e9e, non affili\u00e9e \u00e0 un h\u00f4pital. En cons\u00e9quence, certains services ne pourront \u00eatre offerts sur place. Les cas d\u2019urgence ou d\u2019infection n\u00e9cessitant une prise en charge imm\u00e9diate (moins de 4 semaines) devront \u00eatre r\u00e9f\u00e9r\u00e9s directement en centre hospitalier ou la clinique d\u2019ophtalmologie de votre choix, offrant\ndes services d\u2019urgence.<\/div><div id=\"field_23_197\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_197\"><h3 class=\"gsection_title\">COORDONN\u00c9ES DU PATIENT<\/h3><\/div><div id=\"field_23_1\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_1\"><label class='gfield_label gform-field-label' for='input_23_1' >Nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_23_1' type='text' value='' class='large'    placeholder='Nom*' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_2\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_2\"><label class='gfield_label gform-field-label' for='input_23_2' >Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_23_2' type='text' value='' class='large'    placeholder='Pr\u00e9nom*' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_23_4\"  class=\"gfield gfield--type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_4\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Adresse<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_23_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_23_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_23_4_1' value=''   placeholder='Rue' aria-required='false'    \/>\n                                        <label for='input_23_4_1' id='input_23_4_1_label' class='gform-field-label gform-field-label--type-sub '>Rue<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_23_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_23_4_3' value=''   placeholder='Ville' aria-required='false'    \/>\n                                    <label for='input_23_4_3' id='input_23_4_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_23_4_4_container' >\n                                        <input type='text' name='input_4.4' id='input_23_4_4' value=''     placeholder='Province' aria-required='false'    \/>\n                                        <label for='input_23_4_4' id='input_23_4_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_23_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_23_4_5' value=''   placeholder='Code postal' aria-required='false'    \/>\n                                    <label for='input_23_4_5' id='input_23_4_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_23_4_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_23_5\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_5\"><label class='gfield_label gform-field-label' for='input_23_5' >Date de naissance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_23_5' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='Date de naissance*' aria-describedby=\"input_23_5_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_23_5_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_23_5' class='gform_hidden' value='https:\/\/coi.iris.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_23_6\"  class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_6\"><label class='gfield_label gform-field-label' for='input_23_6' >\u00c2ge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_6' id='input_23_6' type='text'    value='' class='large'    placeholder='\u00c2ge*' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_23_6\" \/><div class='gfield_description instruction ' id='gfield_instruction_23_6'>Please enter a number from <strong>18<\/strong> to <strong>150<\/strong>.<\/div><\/div><\/div><div id=\"field_23_8\"  class=\"gfield gfield--type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_8\"><label class='gfield_label gform-field-label' for='input_23_8' >T\u00e9l\u00e9phone 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_23_8' type='text' value='' class='large'  placeholder='T\u00e9l\u00e9phone 1*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_9\"  class=\"gfield gfield--type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_9\"><label class='gfield_label gform-field-label' for='input_23_9' >T\u00e9l\u00e9phone 2<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_23_9' type='text' value='' class='large'  placeholder='T\u00e9l\u00e9phone 2'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_23_10\"  class=\"gfield gfield--type-email gfield--width-third field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_10\"><label class='gfield_label gform-field-label' for='input_23_10' >Courriel<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_10' id='input_23_10' type='text' value='' class='large'   placeholder='Courriel'  aria-invalid=\"false\" aria-describedby=\"gfield_description_23_10\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_23_10'>*Information importantes afin de communiquer rapidement avec votre patient.<\/div><\/div><div id=\"field_23_12\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_12\"><h3>INFORMATIONS DU R\u00c9F\u00c9RENT<\/h3><\/div><div id=\"field_23_13\"  class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_13\"><label class='gfield_label gform-field-label' for='input_23_13' >Clinique du r\u00e9f\u00e9rent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_23_13' type='text' value='' class='large'    placeholder='Clinique du r\u00e9f\u00e9rent*' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_7\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_7\"><label class='gfield_label gform-field-label' for='input_23_7' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_23_7' type='text' value='' class='datepicker gform-datepicker ymd_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='Date de l&#039;examen' aria-describedby=\"input_23_7_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_23_7_date_format' class='screen-reader-text'>YYYY dash MM dash DD<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_23_7' class='gform_hidden' value='https:\/\/coi.iris.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_23_25\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_25\"><h3 class=\"gsection_title\">CHIRURGIE R\u00c9FRACTIVE<\/h3><\/div><fieldset id=\"field_23_31\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_31\"><legend class='gfield_label gform-field-label'  >Type de chirurgie<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_31'>\n\t\t\t<div class='gchoice gchoice_23_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Laser corn\u00e9en'  id='choice_23_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_31_0' id='label_23_31_0' class='gform-field-label gform-field-label--type-inline'>Laser corn\u00e9en<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Remplacement de cristallin'  id='choice_23_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_31_1' id='label_23_31_1' class='gform-field-label gform-field-label--type-inline'>Remplacement de cristallin<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_23\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_23\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Souhaite autonomie sans lunettes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_23'><div class='gchoice gchoice_23_23_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.1' type='checkbox'  value='VP'  id='choice_23_23_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_23_1' id='label_23_23_1' class='gform-field-label gform-field-label--type-inline'>VP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_23_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.2' type='checkbox'  value='VL et VInterm'  id='choice_23_23_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_23_2' id='label_23_23_2' class='gform-field-label gform-field-label--type-inline'>VL et VInterm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_23_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_23.3' type='checkbox'  value='VL'  id='choice_23_23_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_23_3' id='label_23_23_3' class='gform-field-label gform-field-label--type-inline'>VL<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_24\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_24\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Ouverture aux compromis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_24'><div class='gchoice gchoice_23_24_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.1' type='checkbox'  value='Accepterait monovision'  id='choice_23_24_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_24_1' id='label_23_24_1' class='gform-field-label gform-field-label--type-inline'>Accepterait monovision<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_24_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.2' type='checkbox'  value='Accepterait halos'  id='choice_23_24_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_24_2' id='label_23_24_2' class='gform-field-label gform-field-label--type-inline'>Accepterait halos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_24_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_24.3' type='checkbox'  value='Accepterait baisse de contrastes'  id='choice_23_24_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_24_3' id='label_23_24_3' class='gform-field-label gform-field-label--type-inline'>Accepterait baisse de contrastes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_30\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_30\"><legend class='gfield_label gform-field-label'  >\u00c0 eu une chirurgie r\u00e9fractive dans le pass\u00e9<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_30'>\n\t\t\t<div class='gchoice gchoice_23_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Oui'  id='choice_23_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_30_0' id='label_23_30_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Non'  id='choice_23_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_30_1' id='label_23_30_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_34\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_34\"><label class='gfield_label gform-field-label' for='input_23_34' >Pr\u00e9cision chirurgie ant\u00e9rieure - CHIRURGIE R\u00c9FRACTIVE<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_23_34' type='text' value='' class='large'    placeholder='Veuillez pr\u00e9ciser'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_26\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_26\"><h3 class=\"gsection_title\">CHIRURGIE DE LA CATARACTE<\/h3><\/div><fieldset id=\"field_23_27\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_27\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Port de lunettes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_27'><div class='gchoice gchoice_23_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Le port de lunettes ne lui d\u00e9range pas'  id='choice_23_27_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_27_1' id='label_23_27_1' class='gform-field-label gform-field-label--type-inline'>Le port de lunettes ne lui d\u00e9range pas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_28\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_28\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Souhaite autonomie sans lunettes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_28'><div class='gchoice gchoice_23_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='VP'  id='choice_23_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_28_1' id='label_23_28_1' class='gform-field-label gform-field-label--type-inline'>VP<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='VL et VInterm'  id='choice_23_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_28_2' id='label_23_28_2' class='gform-field-label gform-field-label--type-inline'>VL et VInterm<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='VL'  id='choice_23_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_28_3' id='label_23_28_3' class='gform-field-label gform-field-label--type-inline'>VL<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_32\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_32\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Ouverture aux compromis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_32'><div class='gchoice gchoice_23_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Accepterait monovision'  id='choice_23_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_32_1' id='label_23_32_1' class='gform-field-label gform-field-label--type-inline'>Accepterait monovision<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='Accepterait halos'  id='choice_23_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_32_2' id='label_23_32_2' class='gform-field-label gform-field-label--type-inline'>Accepterait halos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='Accepterait baisse de contrastes'  id='choice_23_32_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_32_3' id='label_23_32_3' class='gform-field-label gform-field-label--type-inline'>Accepterait baisse de contrastes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_33\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_33\"><legend class='gfield_label gform-field-label'  >\u00c0 eu une chirurgie r\u00e9fractive dans le pass\u00e9<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_33'>\n\t\t\t<div class='gchoice gchoice_23_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Oui'  id='choice_23_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_33_0' id='label_23_33_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Non'  id='choice_23_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_33_1' id='label_23_33_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_35\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_35\"><label class='gfield_label gform-field-label' for='input_23_35' >Pr\u00e9cision chirurgie ant\u00e9rieure - CHIRURGIE CATARACTE<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_23_35' type='text' value='' class='large'    placeholder='Veuillez pr\u00e9ciser'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_36\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_36\"><h3 class=\"gsection_title\">OPHTALMO G\u00c9N\u00c9RALE<\/h3><\/div><fieldset id=\"field_23_40\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_40\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Segment post\u00e9rieur<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_40'><div class='gchoice gchoice_23_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='D\u00e9pistage\/suivi glaucome'  id='choice_23_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_40_1' id='label_23_40_1' class='gform-field-label gform-field-label--type-inline'>D\u00e9pistage\/suivi glaucome<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='DMLA s\u00e8che'  id='choice_23_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_40_2' id='label_23_40_2' class='gform-field-label gform-field-label--type-inline'>DMLA s\u00e8che<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Membrane \u00e9pir\u00e9tinienne'  id='choice_23_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_40_3' id='label_23_40_3' class='gform-field-label gform-field-label--type-inline'>Membrane \u00e9pir\u00e9tinienne<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Suivi r\u00e9tinopathie diab\u00e9tique'  id='choice_23_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_40_4' id='label_23_40_4' class='gform-field-label gform-field-label--type-inline'>Suivi r\u00e9tinopathie diab\u00e9tique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_40_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.5' type='checkbox'  value='Suivi hydroxychloroquine (Plaquenil)'  id='choice_23_40_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_40_5' id='label_23_40_5' class='gform-field-label gform-field-label--type-inline'>Suivi hydroxychloroquine (Plaquenil)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_37\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_37\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Segment ant\u00e9rieur<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_37'><div class='gchoice gchoice_23_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='\u00c9rosion r\u00e9cidivente'  id='choice_23_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_37_1' id='label_23_37_1' class='gform-field-label gform-field-label--type-inline'>\u00c9rosion r\u00e9cidivente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='S\u00e9cheresse oculaire'  id='choice_23_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_37_2' id='label_23_37_2' class='gform-field-label gform-field-label--type-inline'>S\u00e9cheresse oculaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Rosac\u00e9e oculaire'  id='choice_23_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_37_3' id='label_23_37_3' class='gform-field-label gform-field-label--type-inline'>Rosac\u00e9e oculaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_37_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.4' type='checkbox'  value='Angles i-c \u00e9troits \/ iridotomie'  id='choice_23_37_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_37_4' id='label_23_37_4' class='gform-field-label gform-field-label--type-inline'>Angles i-c \u00e9troits \/ iridotomie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_37_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.5' type='checkbox'  value='Capsulotomie post\u00e9rieure (YAG)'  id='choice_23_37_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_37_5' id='label_23_37_5' class='gform-field-label gform-field-label--type-inline'>Capsulotomie post\u00e9rieure (YAG)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_37_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.6' type='checkbox'  value='D\u00e9pistage k\u00e9ratoc\u00f4ne \/ ectasie'  id='choice_23_37_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_37_6' id='label_23_37_6' class='gform-field-label gform-field-label--type-inline'>D\u00e9pistage k\u00e9ratoc\u00f4ne \/ ectasie<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_239\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_239\"><p>*Ne n\u00e9cessitant pas d'injection anti-VEGF<\/p><\/div><div id=\"field_23_240\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_240\"><p>*Sans indication chirurgicale (MAVC mieux que 20\/40)<\/p><\/div><div id=\"field_23_241\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_241\"><p>*N\u00e9cessitant traitement tel que : m\u00e9dication oculaire ou syst\u00e9mique, bouchons lacrymaux.<\/p><\/div><div id=\"field_23_242\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_242\"><p>*Sans indication chirurgicale<\/p><\/div><div id=\"field_23_42\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_42\"><label class='gfield_label gform-field-label' for='input_23_42' >Autre pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_23_42' type='text' value='' class='large'    placeholder='Autre (pr\u00e9cisez)'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_41\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_41\"><label class='gfield_label gform-field-label' for='input_23_41' >Autre pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_23_41' type='text' value='' class='large'    placeholder='Autre (pr\u00e9cisez)'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_46\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_46\"><h3 class=\"gsection_title\">NEURO-OPHTALMOLOGIE<\/h3><\/div><fieldset id=\"field_23_47\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_47\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Motif de la r\u00e9f\u00e9rence<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_47'><div class='gchoice gchoice_23_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Diplopie'  id='choice_23_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_1' id='label_23_47_1' class='gform-field-label gform-field-label--type-inline'>Diplopie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Anisocorie'  id='choice_23_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_2' id='label_23_47_2' class='gform-field-label gform-field-label--type-inline'>Anisocorie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Ptose'  id='choice_23_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_3' id='label_23_47_3' class='gform-field-label gform-field-label--type-inline'>Ptose<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Perte d&#039;acuit\u00e9 visuelle'  id='choice_23_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_4' id='label_23_47_4' class='gform-field-label gform-field-label--type-inline'>Perte d'acuit\u00e9 visuelle<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.5' type='checkbox'  value='Perte de champ visuel'  id='choice_23_47_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_5' id='label_23_47_5' class='gform-field-label gform-field-label--type-inline'>Perte de champ visuel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.6' type='checkbox'  value='Anomalie n.opt. (cong\u00e9nitale\/acquise)'  id='choice_23_47_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_6' id='label_23_47_6' class='gform-field-label gform-field-label--type-inline'>Anomalie n.opt. (cong\u00e9nitale\/acquise)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.7' type='checkbox'  value='Neuropathie optique'  id='choice_23_47_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_7' id='label_23_47_7' class='gform-field-label gform-field-label--type-inline'>Neuropathie optique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.8' type='checkbox'  value='Migraine ophtalmique'  id='choice_23_47_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_8' id='label_23_47_8' class='gform-field-label gform-field-label--type-inline'>Migraine ophtalmique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.9' type='checkbox'  value='Syndrome post-commotionnel'  id='choice_23_47_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_9' id='label_23_47_9' class='gform-field-label gform-field-label--type-inline'>Syndrome post-commotionnel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_47_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.11' type='checkbox'  value='Visual Snow Syndrome'  id='choice_23_47_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_47_11' id='label_23_47_11' class='gform-field-label gform-field-label--type-inline'>Visual Snow Syndrome<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_48\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_48\"><label class='gfield_label gform-field-label' for='input_23_48' >Autre pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_23_48' type='text' value='' class='large'    placeholder='Autre (pr\u00e9cisez)'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_49\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_49\"><h3 class=\"gsection_title\">R\u00c9FRACTION<\/h3><\/div><div id=\"field_23_50\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_50\"><h3 class=\"center\">Oeil Droit<\/h3><\/div><div id=\"field_23_51\"  class=\"gfield gfield--type-html gf_intro gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_51\"><div class=\"gf_six\"><\/div>\n<div class=\"gf_six\">Sph\u00e8re<\/div>\n<div class=\"gf_six\">Cyl.<\/div>\n<div class=\"gf_six\">Axe<\/div>\n<div class=\"gf_six\">Add.<\/div>\n<div class=\"gf_six\">MAVC<\/div><\/div><div id=\"field_23_194\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_194\"><div class=\"gf_intro\"><\/div><div id=\"field_23_52\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_52\"><h4>Rx&nbsp;Lunettes<\/h4><\/div><div id=\"field_23_53\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_53\"><label class='gfield_label gform-field-label' for='input_23_53' >OD - Rx Lunettes - Sph\u00e8re<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_23_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_54\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_54\"><label class='gfield_label gform-field-label' for='input_23_54' >OD - Rx Lunettes - Cyl.<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_23_54' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_56\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_56\"><label class='gfield_label gform-field-label' for='input_23_56' >OD - Rx Lunettes - Axe<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_23_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_55\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_55\"><label class='gfield_label gform-field-label' for='input_23_55' >OD - Rx Lunettes - Add.<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_23_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_57\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_57\"><label class='gfield_label gform-field-label' for='input_23_57' >OD - Rx Lunettes - MAVC<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_23_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_195\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_195\"><\/div><\/div><div id=\"field_23_180\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_180\"><div class=\"gf_intro\"><\/div><div id=\"field_23_179\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_179\"><h4>Rx&nbsp;Manifeste<\/h4><\/div><div id=\"field_23_59\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_59\"><label class='gfield_label gform-field-label' for='input_23_59' >OD - Rf manifeste - Sph\u00e8re<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_23_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_60\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_60\"><label class='gfield_label gform-field-label' for='input_23_60' >OD - Rf manifeste - Cyl.<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_23_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_61\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_61\"><label class='gfield_label gform-field-label' for='input_23_61' >OD - Rf manifeste - Axe<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_23_61' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_63\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_63\"><label class='gfield_label gform-field-label' for='input_23_63' >OD - Rf manifeste - Add.<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_23_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_62\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_62\"><label class='gfield_label gform-field-label' for='input_23_62' >OD - Rf manifeste - MAVC<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_23_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_173\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_173\"><\/div><\/div><div id=\"field_23_182\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_182\"><div class=\"gf_intro\"><\/div><div id=\"field_23_181\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_181\"><h4>Rx verres de contact<\/h4><\/div><div id=\"field_23_65\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_65\"><label class='gfield_label gform-field-label' for='input_23_65' >OD - Rx verres de contact - Sph\u00e8re<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_23_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_66\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_66\"><label class='gfield_label gform-field-label' for='input_23_66' >OD - Rx verres de contact - Cyl.<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_23_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_67\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_67\"><label class='gfield_label gform-field-label' for='input_23_67' >OD - Rx verres de contact - Axe<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_23_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_68\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_68\"><label class='gfield_label gform-field-label' for='input_23_68' >OD - Rx verres de contact - Add.<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_23_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_69\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_69\"><label class='gfield_label gform-field-label' for='input_23_69' >OD - Rx verres de contact - MAVC<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_23_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_175\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_175\"><\/div><\/div><div id=\"field_23_184\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_184\"><div class=\"gf_intro\"><\/div><div id=\"field_23_183\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_183\"><h4>K\u00e9rato<\/h4><\/div><div id=\"field_23_71\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_71\"><label class='gfield_label gform-field-label' for='input_23_71' >OD - K\u00e9rato - Valeur 1<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_23_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_72\"  class=\"gfield gfield--type-text gfield--width-full gf_six a_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_72\"><label class='gfield_label gform-field-label' for='input_23_72' >OD - K\u00e9rato - Valeur 2<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_23_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_73\"  class=\"gfield gfield--type-text gfield--width-full gf_six x_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_73\"><label class='gfield_label gform-field-label' for='input_23_73' >OD - K\u00e9rato - Valeur 3<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_23_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_74\"  class=\"gfield gfield--type-text gfield--width-full gf_six a_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_74\"><label class='gfield_label gform-field-label' for='input_23_74' >OD - K\u00e9rato - Valeur 4<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_23_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_177\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_177\"><\/div><\/div><div id=\"field_23_203\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_203\"><div class=\"gf_intro\"><\/div><div id=\"field_23_204\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_204\"><h4>Pachym\u00e9trie<\/h4><\/div><div id=\"field_23_103\"  class=\"gfield gfield--type-text gfield--width-full gf_six microns_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_103\"><label class='gfield_label gform-field-label' for='input_23_103' >OD - Pachy (centrale)<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_23_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_205\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_205\"><\/div><\/div><div id=\"field_23_264\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_264\"><div class=\"gf_intro\"><\/div><div id=\"field_23_263\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_263\"><h4>PIO<\/h4><\/div><div id=\"field_23_208\"  class=\"gfield gfield--type-text gfield--width-full gf_six mmHG_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_208\"><label class='gfield_label gform-field-label' for='input_23_208' >OD - PIO<\/label><div class='ginput_container ginput_container_text'><input name='input_208' id='input_23_208' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_262\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_262\"><\/div><\/div><div id=\"field_23_185\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_185\"><h3 class=\"center\">Oeil Gauche<\/h3><\/div><div id=\"field_23_82\"  class=\"gfield gfield--type-html gfield--width-full gf_intro gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_82\"><div class=\"gf_six\"><\/div>\n<div class=\"gf_six\">Sph\u00e8re<\/div>\n<div class=\"gf_six\">Cyl.<\/div>\n<div class=\"gf_six\">Axe<\/div>\n<div class=\"gf_six\">Add.<\/div>\n<div class=\"gf_six\">MAVC<\/div><\/div><div id=\"field_23_186\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_186\"><div class=\"gf_intro\"><\/div><div id=\"field_23_83\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_83\"><h4>Rx&nbsp;Lunettes<\/h4><\/div><div id=\"field_23_76\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_76\"><label class='gfield_label gform-field-label' for='input_23_76' >OS - Rx Lunettes - Sph\u00e8re<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_23_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_77\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_77\"><label class='gfield_label gform-field-label' for='input_23_77' >OS - Rx Lunettes - Cyl.<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_23_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_78\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_78\"><label class='gfield_label gform-field-label' for='input_23_78' >OS - Rx Lunettes - Axe<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_23_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_79\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_79\"><label class='gfield_label gform-field-label' for='input_23_79' >OS - Rx Lunettes - Add.<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_23_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_80\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_80\"><label class='gfield_label gform-field-label' for='input_23_80' >OS - Rx Lunettes - MAVC<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_23_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_81\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_81\"><\/div><\/div><div id=\"field_23_188\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_188\"><div class=\"gf_intro\"><\/div><div id=\"field_23_187\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_187\"><h4>Rf&nbsp;Manifeste<\/h4><\/div><div id=\"field_23_84\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_84\"><label class='gfield_label gform-field-label' for='input_23_84' >OS - Rf manifeste - Sph\u00e8re<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_23_84' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_85\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_85\"><label class='gfield_label gform-field-label' for='input_23_85' >OS - Rf manifeste - Cyl.<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_23_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_86\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_86\"><label class='gfield_label gform-field-label' for='input_23_86' >OS - Rf manifeste - Axe<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_23_86' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_87\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_87\"><label class='gfield_label gform-field-label' for='input_23_87' >OS - Rf manifeste - Add.<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_23_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_88\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_88\"><label class='gfield_label gform-field-label' for='input_23_88' >OS - Rf manifeste - MAVC<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_23_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_89\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_89\"><\/div><\/div><div id=\"field_23_190\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_190\"><div class=\"gf_intro\"><\/div><div id=\"field_23_189\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_189\"><h4>Rx verres de contact<\/h4><\/div><div id=\"field_23_90\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_90\"><label class='gfield_label gform-field-label' for='input_23_90' >OS - Rx verres de contact - Sph\u00e8re<\/label><div class='ginput_container ginput_container_text'><input name='input_90' id='input_23_90' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_91\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_91\"><label class='gfield_label gform-field-label' for='input_23_91' >OS - Rx verres de contact - Cyl.<\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_23_91' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_92\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_92\"><label class='gfield_label gform-field-label' for='input_23_92' >OS - Rx verres de contact - Axe<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_23_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_93\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_93\"><label class='gfield_label gform-field-label' for='input_23_93' >OS - Rx verres de contact - Add.<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_23_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_96\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_96\"><label class='gfield_label gform-field-label' for='input_23_96' >OS - Rx verres de contact - MAVC<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_23_96' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_95\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_95\"><\/div><\/div><div id=\"field_23_192\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_192\"><div class=\"gf_intro\"><\/div><div id=\"field_23_191\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_191\"><h4>K\u00e9rato<\/h4><\/div><div id=\"field_23_94\"  class=\"gfield gfield--type-text gfield--width-full gf_six field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_94\"><label class='gfield_label gform-field-label' for='input_23_94' >OS - K\u00e9rato - Valeur 1<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_23_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_97\"  class=\"gfield gfield--type-text gfield--width-full gf_six a_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_97\"><label class='gfield_label gform-field-label' for='input_23_97' >OS - K\u00e9rato - Valeur 2<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_23_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_98\"  class=\"gfield gfield--type-text gfield--width-full gf_six x_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_98\"><label class='gfield_label gform-field-label' for='input_23_98' >OS - K\u00e9rato - Valeur 3<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_23_98' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_99\"  class=\"gfield gfield--type-text gfield--width-full gf_six a_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_99\"><label class='gfield_label gform-field-label' for='input_23_99' >OS - K\u00e9rato - Valeur 4<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_23_99' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_100\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_100\"><\/div><\/div><div id=\"field_23_210\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_210\"><div class=\"gf_intro\"><\/div><div id=\"field_23_212\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_212\"><h4>Pachym\u00e9trie<\/h4><\/div><div id=\"field_23_104\"  class=\"gfield gfield--type-text gfield--width-full gf_six microns_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_104\"><label class='gfield_label gform-field-label' for='input_23_104' >OS - Pachy (centrale)<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_23_104' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_211\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_211\"><\/div><\/div><div id=\"field_23_213\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_213\"><div class=\"gf_intro\"><\/div><div id=\"field_23_220\"  class=\"gfield gfield--type-html gfield--width-full gf_six first_el gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_220\"><h4>PIO<\/h4><\/div><div id=\"field_23_215\"  class=\"gfield gfield--type-text gfield--width-full gf_six mmHG_label field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_215\"><label class='gfield_label gform-field-label' for='input_23_215' >OS - PIO<\/label><div class='ginput_container ginput_container_text'><input name='input_215' id='input_23_215' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_214\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_214\"><\/div><\/div><div id=\"field_23_216\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_216\"><h3 class=\"gsection_title\">EXAMEN OCULO-VISUEL<\/h3><\/div><div id=\"field_23_105\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_105\"><h3 style=\"font-weight: bold;\">Corn\u00e9e<\/h3><\/div><fieldset id=\"field_23_108\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_108\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >OD - Corn\u00e9e<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_108'><div class='gchoice gchoice_23_108_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.1' type='checkbox'  value='Dans les limites de la normale'  id='choice_23_108_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_108_1' id='label_23_108_1' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_108_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.2' type='checkbox'  value='DMBE'  id='choice_23_108_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_108_2' id='label_23_108_2' class='gform-field-label gform-field-label--type-inline'>DMBE<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_108_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.3' type='checkbox'  value='Cornea guttata'  id='choice_23_108_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_108_3' id='label_23_108_3' class='gform-field-label gform-field-label--type-inline'>Cornea guttata<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_109\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_109\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >OS - Corn\u00e9e<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_109'><div class='gchoice gchoice_23_109_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.1' type='checkbox'  value='Dans les limites de la normale'  id='choice_23_109_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_109_1' id='label_23_109_1' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_109_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.2' type='checkbox'  value='DMBE'  id='choice_23_109_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_109_2' id='label_23_109_2' class='gform-field-label gform-field-label--type-inline'>DMBE<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_109_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_109.3' type='checkbox'  value='Cornea guttata'  id='choice_23_109_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_109_3' id='label_23_109_3' class='gform-field-label gform-field-label--type-inline'>Cornea guttata<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_122\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_122\"><label class='gfield_label gform-field-label' for='input_23_122' >OD - Corn\u00e9e - Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_23_122' type='text' value='' class='large'    placeholder='Autre :'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_123\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_123\"><label class='gfield_label gform-field-label' for='input_23_123' >OS - Corn\u00e9e - Autre<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_23_123' type='text' value='' class='large'    placeholder='Autre :'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_110\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_110\"><h3 style=\"font-weight: bold;\">Cristallin<\/h3><\/div><fieldset id=\"field_23_112\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_112\"><legend class='gfield_label gform-field-label'  >OD - Cristallin<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_112'>\n\t\t\t<div class='gchoice gchoice_23_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Dans les limites de la normale'  id='choice_23_112_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_112_0' id='label_23_112_0' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Cataracte'  id='choice_23_112_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_112_1' id='label_23_112_1' class='gform-field-label gform-field-label--type-inline'>Cataracte<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_112_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Pseudophaque'  id='choice_23_112_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_112_2' id='label_23_112_2' class='gform-field-label gform-field-label--type-inline'>Pseudophaque<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_112_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='gf_other_choice'  id='choice_23_112_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_112_3' id='label_23_112_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_23_112_other' class='gchoice_other_control' name='input_112_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_111\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_111\"><legend class='gfield_label gform-field-label'  >OS - Cristallin<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_111'>\n\t\t\t<div class='gchoice gchoice_23_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Dans les limites de la normale'  id='choice_23_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_111_0' id='label_23_111_0' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Cataracte'  id='choice_23_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_111_1' id='label_23_111_1' class='gform-field-label gform-field-label--type-inline'>Cataracte<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_111_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Pseudophake'  id='choice_23_111_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_111_2' id='label_23_111_2' class='gform-field-label gform-field-label--type-inline'>Pseudophake<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_111_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='gf_other_choice'  id='choice_23_111_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_111_3' id='label_23_111_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_23_111_other' class='gchoice_other_control' name='input_111_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_115\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_115\"><h3 style=\"font-weight: bold;\">R\u00e9tine<\/h3><\/div><fieldset id=\"field_23_118\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_118\"><legend class='gfield_label gform-field-label'  >OD - R\u00e9tine<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_118'>\n\t\t\t<div class='gchoice gchoice_23_118_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='Dans les limites de la normale'  id='choice_23_118_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_118_0' id='label_23_118_0' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_118_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_118' type='radio' value='Particularit\u00e9 :'  id='choice_23_118_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_118_1' id='label_23_118_1' class='gform-field-label gform-field-label--type-inline'>Particularit\u00e9 :<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_119\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_119\"><legend class='gfield_label gform-field-label'  >OS - R\u00e9tine<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_119'>\n\t\t\t<div class='gchoice gchoice_23_119_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='Dans les limites de la normale'  id='choice_23_119_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_119_0' id='label_23_119_0' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_119_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_119' type='radio' value='Particularit\u00e9 :'  id='choice_23_119_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_119_1' id='label_23_119_1' class='gform-field-label gform-field-label--type-inline'>Particularit\u00e9 :<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_124\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_124\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >OD - R\u00e9tine - Choix particularit\u00e9<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_124'><div class='gchoice gchoice_23_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='Macula'  id='choice_23_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_124_1' id='label_23_124_1' class='gform-field-label gform-field-label--type-inline'>Macula<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_124_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.2' type='checkbox'  value='Nerf optique'  id='choice_23_124_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_124_2' id='label_23_124_2' class='gform-field-label gform-field-label--type-inline'>Nerf optique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_124_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.3' type='checkbox'  value='R\u00e9tine'  id='choice_23_124_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_124_3' id='label_23_124_3' class='gform-field-label gform-field-label--type-inline'>R\u00e9tine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_124_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.4' type='checkbox'  value='Vitr\u00e9'  id='choice_23_124_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_124_4' id='label_23_124_4' class='gform-field-label gform-field-label--type-inline'>Vitr\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_199\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_199\"><\/div><div id=\"field_23_200\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_200\"><\/div><fieldset id=\"field_23_126\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_126\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >OS - R\u00e9tine - Choix particularit\u00e9<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_126'><div class='gchoice gchoice_23_126_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.1' type='checkbox'  value='Macula'  id='choice_23_126_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_126_1' id='label_23_126_1' class='gform-field-label gform-field-label--type-inline'>Macula<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_126_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.2' type='checkbox'  value='Nerf optique'  id='choice_23_126_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_126_2' id='label_23_126_2' class='gform-field-label gform-field-label--type-inline'>Nerf optique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_126_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.3' type='checkbox'  value='R\u00e9tine'  id='choice_23_126_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_126_3' id='label_23_126_3' class='gform-field-label gform-field-label--type-inline'>R\u00e9tine<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_126_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_126.4' type='checkbox'  value='Vitr\u00e9'  id='choice_23_126_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_126_4' id='label_23_126_4' class='gform-field-label gform-field-label--type-inline'>Vitr\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_274\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_274\"><\/div><div id=\"field_23_273\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_273\"><\/div><div id=\"field_23_120\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_120\"><label class='gfield_label gform-field-label' for='input_23_120' >OD - R\u00e9tine pr\u00e9cisions<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_23_120' type='text' value='' class='large'    placeholder='Pr\u00e9cisions r\u00e9tine - OD'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_201\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_201\"><\/div><div id=\"field_23_202\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_202\"><\/div><div id=\"field_23_121\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_121\"><label class='gfield_label gform-field-label' for='input_23_121' >OS - R\u00e9tine pr\u00e9cisions<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_23_121' type='text' value='' class='large'    placeholder='Pr\u00e9cisions r\u00e9tine - OS'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_127\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_127\"><h3 style=\"font-weight: bold;\">Champ visuel<\/h3><\/div><fieldset id=\"field_23_130\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_130\"><legend class='gfield_label gform-field-label'  >OD - Champ visuel<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_130'>\n\t\t\t<div class='gchoice gchoice_23_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Dans les limites de la normale'  id='choice_23_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_130_0' id='label_23_130_0' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Particularit\u00e9 :'  id='choice_23_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_130_1' id='label_23_130_1' class='gform-field-label gform-field-label--type-inline'>Particularit\u00e9 :<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_245\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_245\"><legend class='gfield_label gform-field-label'  >OS - Champ visuel<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_245'>\n\t\t\t<div class='gchoice gchoice_23_245_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='Dans les limites de la normale'  id='choice_23_245_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_245_0' id='label_23_245_0' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_245_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_245' type='radio' value='Particularit\u00e9 :'  id='choice_23_245_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_245_1' id='label_23_245_1' class='gform-field-label gform-field-label--type-inline'>Particularit\u00e9 :<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_243\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_243\"><legend class='gfield_label gform-field-label'  >OD - Particularit\u00e9 Champ visuel<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_243'>\n\t\t\t<div class='gchoice gchoice_23_243_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='D\u00e9ficit de longue date'  id='choice_23_243_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_243_0' id='label_23_243_0' class='gform-field-label gform-field-label--type-inline'>D\u00e9ficit de longue date<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_243_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_243' type='radio' value='D\u00e9ficit soudain'  id='choice_23_243_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_243_1' id='label_23_243_1' class='gform-field-label gform-field-label--type-inline'>D\u00e9ficit soudain<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_275\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_275\"><\/div><div id=\"field_23_276\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_276\"><\/div><fieldset id=\"field_23_246\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_246\"><legend class='gfield_label gform-field-label'  >OS - Particularit\u00e9 Champ visuel<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_246'>\n\t\t\t<div class='gchoice gchoice_23_246_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_246' type='radio' value='D\u00e9ficit de longue date'  id='choice_23_246_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_246_0' id='label_23_246_0' class='gform-field-label gform-field-label--type-inline'>D\u00e9ficit de longue date<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_246_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_246' type='radio' value='D\u00e9ficit soudain'  id='choice_23_246_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_246_1' id='label_23_246_1' class='gform-field-label gform-field-label--type-inline'>D\u00e9ficit soudain<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_271\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_271\"><\/div><div id=\"field_23_272\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_272\"><\/div><div id=\"field_23_244\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_244\"><label class='gfield_label gform-field-label' for='input_23_244' >OD - Pr\u00e9cisez Champ visuel<\/label><div class='ginput_container ginput_container_text'><input name='input_244' id='input_23_244' type='text' value='' class='large'    placeholder='Pr\u00e9cisez champ visuel OD'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_269\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_269\"><\/div><div id=\"field_23_270\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_270\"><\/div><div id=\"field_23_247\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_247\"><label class='gfield_label gform-field-label' for='input_23_247' >OS - Pr\u00e9cisez Champ visuel<\/label><div class='ginput_container ginput_container_text'><input name='input_247' id='input_23_247' type='text' value='' class='large'    placeholder='Pr\u00e9cisez champ visuel OD'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_134\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_134\"><h3 style=\"font-weight: bold;\">Perte d'acuit\u00e9 visuelle<\/h3><\/div><fieldset id=\"field_23_137\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_137\"><legend class='gfield_label gform-field-label'  >OD - Perte d&#039;acuit\u00e9 visuelle<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_137'>\n\t\t\t<div class='gchoice gchoice_23_137_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Non'  id='choice_23_137_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_137_0' id='label_23_137_0' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_137_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_137' type='radio' value='Particularit\u00e9 :'  id='choice_23_137_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_137_1' id='label_23_137_1' class='gform-field-label gform-field-label--type-inline'>Particularit\u00e9 :<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_250\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_250\"><legend class='gfield_label gform-field-label'  >OS - Perte d&#039;acuit\u00e9 visuelle<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_250'>\n\t\t\t<div class='gchoice gchoice_23_250_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Non'  id='choice_23_250_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_250_0' id='label_23_250_0' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_250_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_250' type='radio' value='Particularit\u00e9 :'  id='choice_23_250_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_250_1' id='label_23_250_1' class='gform-field-label gform-field-label--type-inline'>Particularit\u00e9 :<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_248\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_248\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >OD - Particularit\u00e9 Perte d&#039;acuit\u00e9 visuelle<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_248'><div class='gchoice gchoice_23_248_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_248.1' type='checkbox'  value='De longue date'  id='choice_23_248_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_248_1' id='label_23_248_1' class='gform-field-label gform-field-label--type-inline'>De longue date<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_248_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_248.2' type='checkbox'  value='Soudaine\/r\u00e9cente'  id='choice_23_248_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_248_2' id='label_23_248_2' class='gform-field-label gform-field-label--type-inline'>Soudaine\/r\u00e9cente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_248_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_248.3' type='checkbox'  value='Transitoire'  id='choice_23_248_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_248_3' id='label_23_248_3' class='gform-field-label gform-field-label--type-inline'>Transitoire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_248_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_248.4' type='checkbox'  value='Permanente'  id='choice_23_248_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_248_4' id='label_23_248_4' class='gform-field-label gform-field-label--type-inline'>Permanente<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_277\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_277\"><\/div><div id=\"field_23_278\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_278\"><\/div><fieldset id=\"field_23_251\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_251\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >OS - Particularit\u00e9 Perte d&#039;acuit\u00e9 visuelle<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_251'><div class='gchoice gchoice_23_251_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.1' type='checkbox'  value='De longue date'  id='choice_23_251_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_251_1' id='label_23_251_1' class='gform-field-label gform-field-label--type-inline'>De longue date<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_251_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.2' type='checkbox'  value='Soudaine\/r\u00e9cente'  id='choice_23_251_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_251_2' id='label_23_251_2' class='gform-field-label gform-field-label--type-inline'>Soudaine\/r\u00e9cente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_251_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.3' type='checkbox'  value='Transitoire'  id='choice_23_251_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_251_3' id='label_23_251_3' class='gform-field-label gform-field-label--type-inline'>Transitoire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_251_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_251.4' type='checkbox'  value='Permanente'  id='choice_23_251_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_251_4' id='label_23_251_4' class='gform-field-label gform-field-label--type-inline'>Permanente<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_280\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_280\"><\/div><div id=\"field_23_279\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_279\"><\/div><div id=\"field_23_249\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_249\"><label class='gfield_label gform-field-label' for='input_23_249' >OD - Pr\u00e9cision Perte d&#039;acuit\u00e9 visuelle<\/label><div class='ginput_container ginput_container_text'><input name='input_249' id='input_23_249' type='text' value='' class='large'    placeholder='OD - Pr\u00e9cision Perte d&#039;acuit\u00e9 visuelle'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_281\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_281\"><\/div><div id=\"field_23_282\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_282\"><\/div><div id=\"field_23_252\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_252\"><label class='gfield_label gform-field-label' for='input_23_252' >OS - Pr\u00e9cision Perte d&#039;acuit\u00e9 visuelle<\/label><div class='ginput_container ginput_container_text'><input name='input_252' id='input_23_252' type='text' value='' class='large'    placeholder='OS - Pr\u00e9cision Perte d&#039;acuit\u00e9 visuelle'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_139\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_139\"><h3 style=\"font-weight: bold;\">Diplopie<\/h3><\/div><fieldset id=\"field_23_255\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_255\"><legend class='gfield_label gform-field-label'  >Diplopie<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_255'>\n\t\t\t<div class='gchoice gchoice_23_255_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Non'  id='choice_23_255_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_255_0' id='label_23_255_0' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_255_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_255' type='radio' value='Particularit\u00e9 :'  id='choice_23_255_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_255_1' id='label_23_255_1' class='gform-field-label gform-field-label--type-inline'>Particularit\u00e9 :<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_284\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_284\"><\/div><fieldset id=\"field_23_253\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_253\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Particularit\u00e9 Diplopie<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_253'><div class='gchoice gchoice_23_253_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_253.1' type='checkbox'  value='De longue date'  id='choice_23_253_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_253_1' id='label_23_253_1' class='gform-field-label gform-field-label--type-inline'>De longue date<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_253_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_253.2' type='checkbox'  value='Soudaine\/r\u00e9cente'  id='choice_23_253_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_253_2' id='label_23_253_2' class='gform-field-label gform-field-label--type-inline'>Soudaine\/r\u00e9cente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_253_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_253.3' type='checkbox'  value='Transitoire'  id='choice_23_253_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_253_3' id='label_23_253_3' class='gform-field-label gform-field-label--type-inline'>Transitoire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_253_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_253.4' type='checkbox'  value='Permanente'  id='choice_23_253_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_253_4' id='label_23_253_4' class='gform-field-label gform-field-label--type-inline'>Permanente<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_283\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_283\"><\/div><div id=\"field_23_143\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_143\"><label class='gfield_label gform-field-label' for='input_23_143' >Diplopie - Pr\u00e9cisez<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_23_143' type='text' value='' class='large'    placeholder='Pr\u00e9cisez Diplopie'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_287\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_287\"><\/div><div id=\"field_23_145\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_145\"><h3 style=\"font-weight: bold;\">Douleur<\/h3><\/div><fieldset id=\"field_23_148\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_148\"><legend class='gfield_label gform-field-label'  >OD - Douleur<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_148'>\n\t\t\t<div class='gchoice gchoice_23_148_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='Non'  id='choice_23_148_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_148_0' id='label_23_148_0' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_148_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='L\u00e9g\u00e8re'  id='choice_23_148_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_148_1' id='label_23_148_1' class='gform-field-label gform-field-label--type-inline'>L\u00e9g\u00e8re<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_148_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='Moyenne'  id='choice_23_148_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_148_2' id='label_23_148_2' class='gform-field-label gform-field-label--type-inline'>Moyenne<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_148_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='\u00c9lev\u00e9e'  id='choice_23_148_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_148_3' id='label_23_148_3' class='gform-field-label gform-field-label--type-inline'>\u00c9lev\u00e9e<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_149\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_149\"><legend class='gfield_label gform-field-label'  >OS - Douleur<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_149'>\n\t\t\t<div class='gchoice gchoice_23_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='Non'  id='choice_23_149_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_149_0' id='label_23_149_0' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='L\u00e9g\u00e8re'  id='choice_23_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_149_1' id='label_23_149_1' class='gform-field-label gform-field-label--type-inline'>L\u00e9g\u00e8re<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_149_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='Moyenne'  id='choice_23_149_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_149_2' id='label_23_149_2' class='gform-field-label gform-field-label--type-inline'>Moyenne<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_149_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='\u00c9lev\u00e9e'  id='choice_23_149_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_149_3' id='label_23_149_3' class='gform-field-label gform-field-label--type-inline'>\u00c9lev\u00e9e<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_150\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_150\"><h3 class=\"gsection_title\">COMPL\u00c9MENT<\/h3><\/div><div id=\"field_23_151\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_151\"><h3 style=\"font-weight: bold;\">Port LC<\/h3><\/div><fieldset id=\"field_23_154\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_154\"><legend class='gfield_label gform-field-label'  >Port LC<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_154'>\n\t\t\t<div class='gchoice gchoice_23_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Non'  id='choice_23_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_154_0' id='label_23_154_0' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Souples'  id='choice_23_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_154_1' id='label_23_154_1' class='gform-field-label gform-field-label--type-inline'>Souples<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_154_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Semi-rigides'  id='choice_23_154_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_154_2' id='label_23_154_2' class='gform-field-label gform-field-label--type-inline'>Semi-rigides<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_155\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_155\"><legend class='gfield_label gform-field-label'  >Correction LC<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_155'>\n\t\t\t<div class='gchoice gchoice_23_155_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='2 yeux VL'  id='choice_23_155_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_155_0' id='label_23_155_0' class='gform-field-label gform-field-label--type-inline'>2 yeux VL<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_155_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Monovision'  id='choice_23_155_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_155_1' id='label_23_155_1' class='gform-field-label gform-field-label--type-inline'>Monovision<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_155_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_155' type='radio' value='Multifocales'  id='choice_23_155_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_155_2' id='label_23_155_2' class='gform-field-label gform-field-label--type-inline'>Multifocales<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_156\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_156\"><h3 style=\"font-weight: bold;\">S\u00e9cheresse oculaire<\/h3><\/div><fieldset id=\"field_23_157\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_157\"><legend class='gfield_label gform-field-label'  >S\u00e9cheresse oculaire<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_157'>\n\t\t\t<div class='gchoice gchoice_23_157_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Dans les limites de la normale'  id='choice_23_157_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_157_0' id='label_23_157_0' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_157_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='Mod\u00e9r\u00e9e'  id='choice_23_157_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_157_1' id='label_23_157_1' class='gform-field-label gform-field-label--type-inline'>Mod\u00e9r\u00e9e<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_157_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_157' type='radio' value='S\u00e9v\u00e8re'  id='choice_23_157_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_157_2' id='label_23_157_2' class='gform-field-label gform-field-label--type-inline'>S\u00e9v\u00e8re<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_23_158\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_158\"><legend class='gfield_label gform-field-label'  >Traitement<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_158'>\n\t\t\t<div class='gchoice gchoice_23_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Aucun'  id='choice_23_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_158_0' id='label_23_158_0' class='gform-field-label gform-field-label--type-inline'>Aucun<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Larmes artificielles'  id='choice_23_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_158_1' id='label_23_158_1' class='gform-field-label gform-field-label--type-inline'>Larmes artificielles<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_158_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='gf_other_choice'  id='choice_23_158_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_158_2' id='label_23_158_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_23_158_other' class='gchoice_other_control' name='input_158_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_159\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_159\"><h3 style=\"font-weight: bold;\">\u0152il dominant<\/h3><\/div><fieldset id=\"field_23_160\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_160\"><legend class='gfield_label gform-field-label'  >\u0152il dominant<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_23_160'>\n\t\t\t<div class='gchoice gchoice_23_160_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='\u0152il droit'  id='choice_23_160_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_160_0' id='label_23_160_0' class='gform-field-label gform-field-label--type-inline'>\u0152il droit<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_23_160_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='\u0152il gauche'  id='choice_23_160_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_23_160_1' id='label_23_160_1' class='gform-field-label gform-field-label--type-inline'>\u0152il gauche<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_161\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_161\"><h3 style=\"font-weight: bold;\">Vision binoculaire<\/h3><\/div><fieldset id=\"field_23_289\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_289\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Vision binoculaire<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_289'><div class='gchoice gchoice_23_289_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_289.1' type='checkbox'  value='Dans les limites de la normale'  id='choice_23_289_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_289_1' id='label_23_289_1' class='gform-field-label gform-field-label--type-inline'>Dans les limites de la normale<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_289_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_289.2' type='checkbox'  value='Amblyopie'  id='choice_23_289_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_289_2' id='label_23_289_2' class='gform-field-label gform-field-label--type-inline'>Amblyopie<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_289_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_289.3' type='checkbox'  value='Strabisme'  id='choice_23_289_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_289_3' id='label_23_289_3' class='gform-field-label gform-field-label--type-inline'>Strabisme<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_289_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_289.4' type='checkbox'  value='Rx prisme'  id='choice_23_289_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_289_4' id='label_23_289_4' class='gform-field-label gform-field-label--type-inline'>Rx prisme<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_259\"  class=\"gfield gfield--type-html gfield--width-half gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_259\"><\/div><div id=\"field_23_258\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_258\"><label class='gfield_label gform-field-label' for='input_23_258' >Vision binoculaire - Pr\u00e9cision<\/label><div class='ginput_container ginput_container_text'><input name='input_258' id='input_23_258' type='text' value='' class='large'    placeholder='Pr\u00e9cisions'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_166\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_166\"><h3 class=\"gsection_title\">COMMENTAIRES \/ INFORMATIONS ADDITIONNELLES<\/h3><\/div><div id=\"field_23_167\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_167\"><label class='gfield_label gform-field-label' for='input_23_167' >COMMENTAIRES<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_167' id='input_23_167' class='textarea large'    placeholder='Ex: Ant\u00e9c\u00e9dents de chirurgie oculaire, hx sant\u00e9 g\u00e9n\u00e9rale\/oculaire personnelle\/familiale.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_23_291\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_291\"><h3>PI\u00c8CE JOINTE<\/h3><\/div><div id=\"field_23_168\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_168\"><label class='gfield_label gform-field-label' for='input_23_168' >PI\u00c8CE JOINTE<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='8388608' \/><input name='input_168' id='input_23_168' type='file' class='large' aria-describedby=\"gfield_upload_rules_23_168 gfield_description_23_168\" onchange='javascript:gformValidateFileSize( this, 8388608 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_23_168'>Accepted file types: pdf, jpeg, Max. file size: 8 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_23_168'><\/div><\/div><div class='gfield_description' id='gfield_description_23_168'>Ex: champ visuel, OCT, photo, rapport.<\/div><\/div><fieldset id=\"field_23_169\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_23_169\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >COMMUNICATION<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_23_169'><div class='gchoice gchoice_23_169_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.1' type='checkbox'  value='SVP veuillez communiquer avec le patient'  id='choice_23_169_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_169_1' id='label_23_169_1' class='gform-field-label gform-field-label--type-inline'>SVP veuillez communiquer avec le patient<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_169_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.2' type='checkbox'  value='Le patient communiquera avec la COI'  id='choice_23_169_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_169_2' id='label_23_169_2' class='gform-field-label gform-field-label--type-inline'>Le patient communiquera avec la COI<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_169_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.3' type='checkbox'  value='Un RV a d\u00e9j\u00e0 \u00e9t\u00e9 planifi\u00e9 pour la consultation'  id='choice_23_169_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_169_3' id='label_23_169_3' class='gform-field-label gform-field-label--type-inline'>Un RV a d\u00e9j\u00e0 \u00e9t\u00e9 planifi\u00e9 pour la consultation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_23_169_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.4' type='checkbox'  value='SVP veuillez communiquer avec moi avant de contacter le patient'  id='choice_23_169_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_23_169_4' id='label_23_169_4' class='gform-field-label gform-field-label--type-inline'>SVP veuillez communiquer avec moi avant de contacter le patient<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_23_14\"  class=\"gfield gfield--type-text gfield--width-full gf_left_half js-field-name gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_14\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_14' >Optom\u00e9triste (nom)<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_23_14' type='text' value='' class='large'    placeholder='Optom\u00e9triste (nom)'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_221\"  class=\"gfield gfield--type-text gfield--width-full js-field-number field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_221\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_221' >No de membre<\/label><div class='ginput_container ginput_container_text'><input name='input_221' id='input_23_221' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_234\"  class=\"gfield gfield--type-text gfield--width-full js-field-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_234\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_234' >Courriel du r\u00e9f\u00e9rent<\/label><div class='ginput_container ginput_container_text'><input name='input_234' id='input_23_234' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_222\"  class=\"gfield gfield--type-text gfield--width-full js-field-clinic1 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_222\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_222' >Clinique 1<\/label><div class='ginput_container ginput_container_text'><input name='input_222' id='input_23_222' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_235\"  class=\"gfield gfield--type-text gfield--width-full js-field-address1 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_235\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_235' >Adresse 1<\/label><div class='ginput_container ginput_container_text'><input name='input_235' id='input_23_235' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_230\"  class=\"gfield gfield--type-text gfield--width-full js-field-phone1 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_230\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_230' >T\u00e9l\u00e9phone 1<\/label><div class='ginput_container ginput_container_text'><input name='input_230' id='input_23_230' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_226\"  class=\"gfield gfield--type-text gfield--width-full js-field-fax1 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_226\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_226' >T\u00e9l\u00e9copieur 1<\/label><div class='ginput_container ginput_container_text'><input name='input_226' id='input_23_226' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_223\"  class=\"gfield gfield--type-text gfield--width-full js-field-clinic2 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_223\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_223' >Clinique 2<\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_23_223' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_236\"  class=\"gfield gfield--type-text gfield--width-full js-field-address2 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_236\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_236' >Adresse 2<\/label><div class='ginput_container ginput_container_text'><input name='input_236' id='input_23_236' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_227\"  class=\"gfield gfield--type-text gfield--width-full js-field-phone2 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_227\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_227' >T\u00e9l\u00e9phone 2<\/label><div class='ginput_container ginput_container_text'><input name='input_227' id='input_23_227' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_231\"  class=\"gfield gfield--type-text gfield--width-full js-field-fax2 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_231\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_231' >T\u00e9l\u00e9copieur 2<\/label><div class='ginput_container ginput_container_text'><input name='input_231' id='input_23_231' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_224\"  class=\"gfield gfield--type-text gfield--width-full js-field-clinic3 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_224\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_224' >Clinique 3<\/label><div class='ginput_container ginput_container_text'><input name='input_224' id='input_23_224' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_237\"  class=\"gfield gfield--type-text gfield--width-full js-field-address3 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_237\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_237' >Adresse 3<\/label><div class='ginput_container ginput_container_text'><input name='input_237' id='input_23_237' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_228\"  class=\"gfield gfield--type-text gfield--width-full js-field-phone3 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_228\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_228' >T\u00e9l\u00e9phone 3<\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_23_228' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_232\"  class=\"gfield gfield--type-text gfield--width-full js-field-fax3 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_232\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_232' >T\u00e9l\u00e9copieur 3<\/label><div class='ginput_container ginput_container_text'><input name='input_232' id='input_23_232' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_225\"  class=\"gfield gfield--type-text gfield--width-full js-field-clinic4 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_225\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_225' >Clinique 4<\/label><div class='ginput_container ginput_container_text'><input name='input_225' id='input_23_225' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_238\"  class=\"gfield gfield--type-text gfield--width-full js-field-address4 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_23_238\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_23_238' >Adresse 4<\/label><div class='ginput_container ginput_container_text'><input name='input_238' id='input_23_238' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_23_229\"  class=\"gfield 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