{"id":2448,"date":"2024-09-17T11:10:54","date_gmt":"2024-09-17T09:10:54","guid":{"rendered":"https:\/\/anatomyandinjections.com\/?page_id=2448"},"modified":"2024-10-15T15:41:44","modified_gmt":"2024-10-15T13:41:44","slug":"devenir-modele-inscription","status":"publish","type":"page","link":"https:\/\/anatomyandinjections.com\/en\/devenir-modele-inscription\/","title":{"rendered":"Devenir mod\u00e8le inscription"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"2448\" class=\"elementor elementor-2448\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ba8bd5f e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no wpr-equal-height-no e-con e-parent\" data-id=\"ba8bd5f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a248b09 elementor-widget elementor-widget-heading\" data-id=\"a248b09\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Become a model <\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-dc75718 e-con-full e-flex wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no wpr-equal-height-no e-con e-child\" data-id=\"dc75718\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-780f2c0 elementor-widget elementor-widget-shortcode\" data-id=\"780f2c0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><form class=\"devnirmedoelform\" action=\"\/en\/wp-json\/wp\/v2\/pages\/2448\" method=\"post\" enctype=\"multipart\/form-data\" data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/2448\">\n        <input type=\"hidden\" name=\"modele_submitted\" value=\"1\">\n        <section>\n\t\t    \n        <div class=\"margindvnrmodele\">\n\n            <h2>Informations personnelles<\/h2>\n            <label>Vous \u00eates:<\/label><br>\n            <input type=\"radio\" name=\"gender\" value=\"female\"> Une femme\n            <input type=\"radio\" name=\"gender\" value=\"male\"> Un homme\n            <input type=\"radio\" name=\"gender\" value=\"non_binary\"> Non genr\u00e9<br>\n        <\/div>\n\n<div class=\"colformd1\">\n<div class=\"colformd2\">\n            <label>Ann\u00e9e de naissance:<\/label>\n            <input type=\"number\" name=\"birth_year\"><br>\n<\/div>\n<div class=\"colformd2\">\n            <label>Je suis affili\u00e9(e) \u00e0 un r\u00e9gime de la s\u00e9curit\u00e9 sociale:<\/label>\n            <select name=\"social_security\">\n                <option value=\"oui\">OUI<\/option>\n                <option value=\"non\">NON<\/option>\n            <\/select><br>\n <\/div>\n  <\/div>\n<div class=\"margindvnrmodele\">\n    <label>Je suis soumis(e) \u00e0 un r\u00e9gime de protection l\u00e9gale (tutelle, curatelle) :<\/label>\n    <input type=\"checkbox\" name=\"protection\" onclick=\"checkProtection(this)\"><br>\n<\/div>\n\n<div id=\"message\" style=\"display: none; color: green;\">\n    Merci pour votre honn\u00eatet\u00e9. Vous n avez pas besoin de continuer ce formulaire. Nous vous souhaitons une excellente journ\u00e9e.\n<\/div>\n        \n<div class=\"colformd1\">\n<div class=\"colformd2\">\n            <label>Pr\u00e9nom:<\/label>\n            <input type=\"text\" name=\"first_name\"><br>\n<\/div>\n<div class=\"colformd2\">\n            <label>Nom:<\/label>\n            <input type=\"text\" name=\"last_name\"><br>\n <\/div>\n  <\/div>\n          <div class=\"margindvnrmodele\">\n\n\n            <label>Adresse postale:<\/label>\n            <input type=\"text\" name=\"address\"><br>\n<\/div>\n\n  <div class=\"colformd1\">\n<div class=\"colformd2\">\n            <label>Code postal:<\/label>\n            <input type=\"text\" name=\"postal_code\"><br>\n<\/div>\n<div class=\"colformd2\">\n            <label>Ville:<\/label>\n            <input type=\"text\" name=\"city\"><br>\n <\/div>\n  <\/div>\n    <div class=\"colformd1\">\n<div class=\"colformd2\">\n            <label>Num\u00e9ro de t\u00e9l\u00e9phone:<\/label>\n            <input type=\"tel\" name=\"phone_number\"><br>\n<\/div>\n<div class=\"colformd2\">\n            <label>Pays:<\/label>\n            <select name=\"country\">\n                <option value=\"france\">France<\/option>\n            <\/select><br>\n <\/div>\n  <\/div>\n            <div class=\"margindvnrmodele\">\n\n            <label>Adresse mail:<\/label>\n            <input type=\"email\" name=\"email\"><br>\n              <\/div>\n\n    <div class=\"colformd1\">\n<div class=\"colformd2\">\n<h3>Photos:<\/h3><br>\n            <p>Formats accept\u00e9s : jpg \/ png \/ pdf<\/p>\n            <p>Fond blanc - Fond uni (mur etc...)<\/p>\n            <p>Cou et d\u00e9collet\u00e9 d\u00e9gag\u00e9<\/p>\n            <p>Bien \u00e9clairer la partie \u00e0 photographier et si possible \u00e0 la lumi\u00e8re naturelle<\/p>\n            <p>Cheveux BIEN tir\u00e9s en arri\u00e8re<\/p>\n            <p>SANS maquillage, SANS bijoux<\/p>\n    <\/div>\n<div class=\"colformd2\">\n<div class=\"photomodlcolformd1\">\n\n    <div class=\"photomodlcolformd2\">\n        <img decoding=\"async\" src=\"https:\/\/anatomyandinjections.com\/wp-content\/uploads\/2024\/09\/Photo_Modele_Face-1.jpg\" alt=\"Image pour le visage\">\n        <h5>Face:<\/h5>\n        <div class=\"file-upload-wrapper\">\n            <button class=\"file-upload-button\">Choisir un fichier<\/button>\n            <input type=\"file\" name=\"photo_face\" accept=\".jpg, .png, .pdf\" required>\n        <\/div>\n    <\/div>\n\n    <div class=\"photomodlcolformd2\">\n        <img decoding=\"async\" src=\"https:\/\/anatomyandinjections.com\/wp-content\/uploads\/2024\/09\/Photo_Modele_Profil-1.jpg\" alt=\"Image pour le profil\">\n        <h5>Profil:<\/h5>\n        <div class=\"file-upload-wrapper\">\n            <button class=\"file-upload-button\">Choisir un fichier<\/button>\n            <input type=\"file\" name=\"photo_profil\" accept=\".jpg, .png, .pdf\" required>\n        <\/div>\n    <\/div>\n\n    <div class=\"photomodlcolformd2\">\n        <img decoding=\"async\" src=\"https:\/\/anatomyandinjections.com\/wp-content\/uploads\/2024\/09\/Photo_Modele_HausserSourcils-1.jpg\" alt=\"Image pour hausser les sourcils\">\n        <h5>Hausser les sourcils:<\/h5>\n        <div class=\"file-upload-wrapper\">\n            <button class=\"file-upload-button\">Choisir un fichier<\/button>\n            <input type=\"file\" name=\"photo_hausser_sourcils\" accept=\".jpg, .png, .pdf\" required>\n        <\/div>\n    <\/div>\n\n    <div class=\"photomodlcolformd2\">\n        <img decoding=\"async\" src=\"https:\/\/anatomyandinjections.com\/wp-content\/uploads\/2024\/09\/Photo_Modele_FroncerSourcils-1.jpg\" alt=\"Image pour froncer les sourcils\">\n        <h5>Froncer les sourcils:<\/h5>\n        <div class=\"file-upload-wrapper\">\n            <button class=\"file-upload-button\">Choisir un fichier<\/button>\n            <input type=\"file\" name=\"photo_froncer_sourcils\" accept=\".jpg, .png, .pdf\" required>\n        <\/div>\n    <\/div>\n\n<\/div>\n\n\n\n\n  <\/div>\n\n        <\/section>\n        \n            <span class=\"DIVIDERFORMMDOELE\"><\/span>\n                      <div class=\"margindvnrmodele\">\n\n                    <h2>Questionnaire m\u00e9dical volontaire (class\u00e9 confidentiel)<\/h2>\n                    \n                      <\/div>\n\n            <div class=\"colformd1\">\n<div class=\"colformd2\">\n\n        <section>\n\n  <label>Je suis enceinte ou en cours d\u2019allaitement :<\/label>\n    <input type=\"checkbox\" name=\"pregnant\" onclick=\"checkPregnancy(this)\"><br>\n<div id=\"message2\" style=\"display: none; color: green;\">\n    Merci pour votre r\u00e9ponse. Vous navez pas besoin de continuer ce formulaire. Nous vous souhaitons tout le meilleur pour cette p\u00e9riode sp\u00e9ciale.\n<\/div>\n\n          \n        <\/section>\n    <\/div>\n<div class=\"colformd2\">\n            <p>L\u02bcassociation ALDECEV \u00abanatomy and injections\u00bb\nne peut pas vous inscrire dans sa base de panel volontaires si : \n\u2022 Vous avez d\u00e9j\u00e0 pr\u00e9sent\u00e9 une r\u00e9action allergique \u00e0 des produits\ncosm\u00e9tiques (r\u00e9action cutan\u00e9e, oculaires, ORL et pulmonaires\ntype asthmatique)\n\u2022 Vous \u00eates enceinte ou en cours d\u02bcallaitement\n\u2022 Vous suivez un traitement contre le cancer\n(y compris hormonoth\u00e9rapie)\n\u2022 Vous \u00eates suivi(e) pour toute maladie chronique ou s\u00e9v\u00e8re\npouvant interferer avec l\u02bc\u00e9valuation du produit et\/ ou la s\u00e9curit\u00e9\ndu volontaire<\/p>\n             <\/div>\n  <\/div>\n  \n     <span class=\"DIVIDERFORMMDOELE\"><\/span>\n        <section>\n                              <div class=\"margindvnrmodele\">\n\n          <h2>Ant\u00e9c\u00e9dents m\u00e9dicaux g\u00e9n\u00e9raux<\/h2>\n            <h3>1. Chirurgical<\/h3>\n              <\/div>\n         <div class=\"colformd1\">\n<div class=\"colformd2\">\n          \n            <label>Avez-vous subi des interventions chirurgicales en g\u00e9n\u00e9ral?<\/label><br>\n            <input type=\"radio\" name=\"general_surgery\" value=\"oui\"> Oui\n            <input type=\"radio\" name=\"general_surgery\" value=\"non\"> No<br>\n\n            <label>Si oui, \u00e9num\u00e9rez-les:<\/label>\n            <input type=\"text\" name=\"general_surgery_list\"><br>\n\n            <label>Avez-vous subi une intervention chirurgicale au niveau du VISAGE les 3 derniers mois?<\/label><br>\n            <input type=\"radio\" name=\"face_surgery_recent\" value=\"oui\"> Oui\n            <input type=\"radio\" name=\"face_surgery_recent\" value=\"non\"> No<br>\n    <\/div>\n<div class=\"colformd2\">\n            <label>Pr\u00e9voyez-vous une intervention chirurgicale au niveau du visage dans les mois qui arrivent?<\/label><br>\n            <input type=\"radio\" name=\"face_surgery_planned\" value=\"oui\"> Oui\n            <input type=\"radio\" name=\"face_surgery_planned\" value=\"non\"> No<br>\n\n            <label>Si oui, \u00e9num\u00e9rez-les:<\/label>\n            <input type=\"text\" name=\"face_surgery_planned_list\"><br>\n                    <\/div>\n  <\/div>\n        <\/section>\n     <span class=\"DIVIDERFORMMDOELE\"><\/span>\n        <section>\n                                      <div class=\"margindvnrmodele\">\n\n            <h3>2. M\u00e9dical<\/h3>\n              <\/div>\n  <label>Avez-vous ou avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9, trait\u00e9 ou re\u00e7u un des \u00e9l\u00e9ments suivants:<\/label><br>\n        \n                 <div class=\"colformd1\">\n<div class=\"colformd2\">\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"recent_fever\"> Fi\u00e8vre r\u00e9cente<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"heart_disease\"> Maladies cardiaques<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"autoimmune_disease\"> Maladie auto-immune<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"diabetes\"> Diab\u00e8te<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"stroke\"> Accident vasculaire c\u00e9r\u00e9bral<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"hiv_aids\"> SIDA ou VIH<br>\n\t\t\t <input type=\"checkbox\" name=\"medical_history[]\" value=\"migraine\"> Migraine<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"maladie_neuro_musculaire\"> Maladie neuro-musculaire<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"probleme_peau\"> Probl\u00e8me de peau<br>\n             <\/div>\n<div class=\"colformd2\">\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"excessive_scarring\"> Cicatrices excessives<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"anaphylactic_shock\"> Choc anaphylactique<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"bleeding_disorder\"> Trouble h\u00e9morragique<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"cold_sores\"> Boutons de fi\u00e8vre(herpes)<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"thyroid_disease\"> Maladie thyro\u00efdienne<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"rheumatoid_arthritis\"> Polyarthrite rhumato\u00efde<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"lupus\"> Lupus \u00e9ryth\u00e9mateux<br>\n                                            <\/div>\n  <\/div>\n\n            <label>\u00cates-vous allergique \u00e0 certains m\u00e9dicaments?<\/label><br>\n            <input type=\"radio\" name=\"medication_allergy\" value=\"oui\"> Oui\n            <input type=\"radio\" name=\"medication_allergy\" value=\"non\"> No<br>\n\n\n            <label>Hypersensibilit\u00e9 connue \u00e0 la neurotoxine botulinique A ou \u00e0 la s\u00e9rum-albumine:<\/label><br>\n            <input type=\"radio\" name=\"botulinum_hypersensitivity\" value=\"oui\"> Oui\n            <input type=\"radio\" name=\"botulinum_hypersensitivity\" value=\"non\"> No<br>\n   \n   \n        <\/section>\n     <span class=\"DIVIDERFORMMDOELE\"><\/span>\n        <section>\n                                              <div class=\"margindvnrmodele\">\n\n            <h2>Ant\u00e9c\u00e9dents esth\u00e9tiques<\/h2>\n            \n              <\/div>\n                    <div class=\"colformd1\">\n<div class=\"colformd2\">\n            <h3>1. Toxine botulique<\/h3>\n            <label>Avez-vous d\u00e9j\u00e0 b\u00e9n\u00e9fici\u00e9 de toxine botulique?<\/label><br>\n          <input type=\"radio\" name=\"botox\" value=\"oui\" id=\"botox_oui\"> Oui\n<input type=\"radio\" name=\"botox\" value=\"non\" id=\"botox_non\"> No<br>\n\n\n<div id=\"botox_date_container\" style=\"display: none;\">\n    <label>Date de la derni\u00e8re injection de toxine botulique:<\/label>\n    <input type=\"date\" name=\"botox_date\" id=\"botox_date\"><br>\n<\/div>\n\n            <label>Zones d\u2019injection de toxine botulique:<\/label><br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"front\"> Front<br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"around_eyes\"> Autour des yeux<br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"glabella\"> Glabelle (rides du lion)<br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"lower_face\"> Bas du visage<br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"chin\"> Menton<br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"armpits\"> Aisselles<br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"masseters\"> Mass\u00e9ters<br>\n            <input type=\"checkbox\" name=\"botox_zones[]\" value=\"other\"> Autre<br>\n    <\/div>\n<div class=\"colformd2\">\n            <h3>2. Acide hyaluronique<\/h3>\n<label>Avez-vous d\u00e9j\u00e0 b\u00e9n\u00e9fici\u00e9 d\u2019injection d\u2019acide hyaluronique?<\/label><br>\n<input type=\"radio\" name=\"hyaluronic_acid\" value=\"oui\" id=\"hyaluronic_acid_oui\"> Oui\n<input type=\"radio\" name=\"hyaluronic_acid\" value=\"non\" id=\"hyaluronic_acid_non\"> No<br>\n<div id=\"hyaluronic_acid_date_container\" style=\"display: none;\">\n    <label>Date de la derni\u00e8re injection d\u2019acide hyaluronique:<\/label>\n    <input type=\"date\" name=\"hyaluronic_acid_date\" id=\"hyaluronic_acid_date\"><br>\n<\/div>\n\n            <label>Zones d\u2019injection d\u2019acide hyaluronique:<\/label><br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"front\"> Front<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"temples\"> Tempes<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"glabella\"> Glabelle (rides du lion)<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"cheeks\"> Pommettes<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"nasolabial_folds\"> Sillons naso-g\u00e9niens<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"cheeks\"> Joues<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"lips\"> L\u00e8vres<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"chin\"> Menton<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"jawline\"> Jawline, Ovale<br>\n            <input type=\"checkbox\" name=\"hyaluronic_acid_zones[]\" value=\"other\"> Autre<br>\n                    <\/div>\n  <\/div>\n                      <div class=\"colformd1\">\n<div class=\"colformd2\">\n            <h3>3. Laser<\/h3>\n           <label>Avez-vous d\u00e9j\u00e0 b\u00e9n\u00e9fici\u00e9 de laser au niveau du visage?<\/label><br>\n<input type=\"radio\" name=\"laser\" value=\"oui\" id=\"laser_oui\"> Oui\n<input type=\"radio\" name=\"laser\" value=\"non\" id=\"laser_non\"> No<br>\n<div id=\"laser_date_container\" style=\"display: none;\">\n    <label>Date de la derni\u00e8re s\u00e9ance de laser:<\/label>\n    <input type=\"date\" name=\"laser_date\" id=\"laser_date\"><br>\n<\/div>\n\n\n            <label>Zones de traitement du laser:<\/label><br>\n            <input type=\"checkbox\" name=\"laser_zones[]\" value=\"upper_face\"> Tiers sup\u00e9rieur du visage<br>\n            <input type=\"checkbox\" name=\"laser_zones[]\" value=\"middle_face\"> Tiers moyen du visage<br>\n            <input type=\"checkbox\" name=\"laser_zones[]\" value=\"lower_face\"> Tiers inf\u00e9rieur du visage<br>\n            <input type=\"checkbox\" name=\"laser_zones[]\" value=\"other\"> Autre<br>\n    <\/div>\n<div class=\"colformd2\">\n            <h3>4. Peeling<\/h3>\n            <label>Avez-vous d\u00e9j\u00e0 b\u00e9n\u00e9fici\u00e9 de peeling au niveau du visage?<\/label><br>\n<input type=\"radio\" name=\"peeling\" value=\"oui\" id=\"peeling_oui\"> Oui\n<input type=\"radio\" name=\"peeling\" value=\"non\" id=\"peeling_non\"> No<br>\n<div id=\"peeling_date_container\" style=\"display: none;\">\n    <label>Date de la derni\u00e8re s\u00e9ance de peeling:<\/label>\n    <input type=\"date\" name=\"peeling_date\" id=\"peeling_date\"><br>\n<\/div>\n\n \n\n            <label>Zones de traitement du peeling:<\/label><br>\n            <input type=\"checkbox\" name=\"peeling_zones[]\" value=\"upper_face\"> Tiers sup\u00e9rieur du visage<br>\n            <input type=\"checkbox\" name=\"peeling_zones[]\" value=\"middle_face\"> Tiers moyen du visage<br>\n            <input type=\"checkbox\" name=\"peeling_zones[]\" value=\"lower_face\"> Tiers inf\u00e9rieur du visage<br>\n            <input type=\"checkbox\" name=\"peeling_zones[]\" value=\"other\"> Autre<br>\n                                <\/div>\n  <\/div>\n        <\/section>\n     <span class=\"DIVIDERFORMMDOELE\"><\/span>\n        <section>\n                                                      <div class=\"margindvnrmodele\">\n\n            <h2>Questionnaire m\u00e9dical g\u00e9n\u00e9ral<\/h2>\n            <label>Avez-vous ou avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostiqu\u00e9, trait\u00e9 ou re\u00e7u un des \u00e9l\u00e9ments suivants:<\/label><br>\n              <\/div>\n                 <div class=\"colformd1\">\n<div class=\"colformd2\">\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"recent_fever\"> Fi\u00e8vre r\u00e9cente<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"heart_disease\"> Maladies cardiaques<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"autoimmune_disease\"> Maladie auto-immune<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"diabetes\"> Diab\u00e8te<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"stroke\"> Accident vasculaire c\u00e9r\u00e9bral<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"hiv_aids\"> SIDA ou VIH<br>\n\t\t\t <input type=\"checkbox\" name=\"medical_history[]\" value=\"Migraine\"> Migraine<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"Maladie_neuro_musculaire\"> Maladie neuro-musculaire<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"Probleme_peau\"> Probl\u00e8me de peau<br>\n             <\/div>\n<div class=\"colformd2\">\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"excessive_scarring\"> Cicatrices excessives<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"anaphylactic_shock\"> Choc anaphylactique<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"bleeding_disorder\"> Trouble h\u00e9morragique<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"cold_sores\"> Boutons de fi\u00e8vre(herpes)<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"thyroid_disease\"> Maladie thyro\u00efdienne<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"rheumatoid_arthritis\"> Polyarthrite rhumato\u00efde<br>\n            <input type=\"checkbox\" name=\"medical_history[]\" value=\"lupus\"> Lupus \u00e9ryth\u00e9mateux<br>\n                                            <\/div>\n  <\/div>\n        <\/section>\n     <span class=\"DIVIDERFORMMDOELE\"><\/span>\n        <section>\n                                                              <div class=\"margindvnrmodele\">\n\n            <h2>Pour rappel : Effets secondaires sp\u00e9cifiques \u00e0 la toxine botulique<\/h2>\n            <p>Effets secondaires \"mineurs\" \u00e0 \"mod\u00e9r\u00e9s\" r\u00e9solutifs en quelques jours en moyenne.<\/p>\n              <\/div>\n            <ul>\n                <li>H\u00e9matome au point d'injection, ecchymose<\/li>\n                <li>Douleur locale<\/li>\n                <li>Rougeur localis\u00e9e<\/li>\n                <li>Trouble de la sensibilit\u00e9<\/li>\n                <li>C\u00e9phal\u00e9es<\/li>\n                <li>Faiblesse musculaire<\/li>\n            <\/ul>\n        <\/section>\n     <span class=\"DIVIDERFORMMDOELE\"><\/span>\n        <section>\n\n<div class=\"colformd1\">\n<div class=\"colformd2\">\n  <label>T\u00e9l\u00e9charger et lire la fiche d\u2019information de la Soci\u00e9t\u00e9 Fran\u00e7ais de Chirurgie Plastique Reconstructrice et Esth\u00e9tique (SOF.CPRE)<\/label><br>\n<\/div>\n<div class=\"colformd2\">\n          <a class=\"buttondvnrmdll\" href=\"https:\/\/prod.anatomyandinjections.com\/wp-content\/uploads\/2024\/06\/Fiche_Information_SOF.CPRE_.pdf\" download>Fiche d\u02bcinformation de la SOF.CPRE<\/a>\n <\/div>\n  <\/div>\n            <input type=\"checkbox\" name=\"sof_cpre_info\" value=\"lu\" required> J\u2019ai lu la fiche d\u2019information de la SOF.CPRE<br>\n\n    <label><\/label>\n    <input type=\"checkbox\" name=\"understood\" value=\"oui\" required> J\u2019ai BIEN compris les \u00e9l\u00e9ments ci-dessus et je peux m\u2019inscrire dans le panel de volontaires<br>\n\n    <label><\/label>\n    <input type=\"checkbox\" name=\"data_consent\" value=\"oui\" required> J\u2019accepte express\u00e9ment que les donn\u00e9es \u00e0 caract\u00e8re personnel me concernant recueillies dans ce questionnaire fassent l\u2019objet d\u2019un traitement informatique par l\u2019association ALDECEV<br>\n\n    <label><\/label>\n    <input type=\"checkbox\" name=\"certification\" value=\"oui\" required> Je certifie que toutes les informations fournies sont v\u00e9ridiques<br>\n\n\t\t\t\n\t\t\t           <label><\/label>\n            <input type=\"checkbox\" name=\"sms_consent\" value=\"oui\"> J\u2019accepte de recevoir des SMS afin de me rappeler mes rendez-vous et de m\u2019avertir en cas d\u2019annulations<br>\n        <\/section>\n\n        <section>\n            <h2>Signature<\/h2>\n            <label>Pays:<\/label>\n            <select name=\"signature_country\">\n                <option value=\"france\">France<\/option>\n            <\/select><br>\n\n            <label>Ville:<\/label>\n            <input type=\"text\" name=\"signature_city\"><br>\n\n            <label>Date:<\/label>\n            <input type=\"date\" name=\"signature_date\"><br>\n\n              <label>Signature \u00e9lectronique:<\/label>\n<div id=\"signature-pad\" class=\"signature-pad\">\n        <canvas width=\"300\" height=\"200\"><\/canvas>\n        <div>\n            <button type=\"button\" id=\"clear-signature\">Effacer<\/button>\n            <button type=\"button\" id=\"save-signature\">Sauvegarder<\/button>\n        <\/div>\n    <\/div>\n    <input type=\"hidden\" name=\"electronic_signature_image\" id=\"electronic_signature_image\">\n            \n        <\/section>\n<br>\n        <button class=\"validermodele\" type=\"submit\">Valider le formulaire<\/button>\n        \n    <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-ce6256e e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no wpr-equal-height-no e-con e-parent\" data-id=\"ce6256e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d490562 elementor-widget elementor-widget-html\" data-id=\"d490562\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>\n    document.addEventListener('DOMContentLoaded', function() {\n    \/\/ S\u00e9lection des \u00e9l\u00e9ments\n    const botoxOui = document.getElementById('botox_oui');\n    const botoxNon = document.getElementById('botox_non');\n    const botoxDate = document.getElementById('botox_date');\n\n    \/\/ Fonction pour d\u00e9sactiver ou activer le champ de date\n    function toggleBotoxDate() {\n        if (botoxNon.checked) {\n            botoxDate.disabled = true;  \/\/ D\u00e9sactive le champ de date si \"Non\" est coch\u00e9\n            botoxDate.value = '';       \/\/ Efface la valeur du champ\n        } else {\n            botoxDate.disabled = false; \/\/ Active le champ de date si \"Oui\" est coch\u00e9\n        }\n    }\n\n    \/\/ \u00c9couter les changements dans les choix radio\n    botoxOui.addEventListener('change', toggleBotoxDate);\n    botoxNon.addEventListener('change', toggleBotoxDate);\n\n    \/\/ Appeler la fonction au chargement pour g\u00e9rer les \u00e9tats initiaux\n    toggleBotoxDate();\n});\n\n\ndocument.addEventListener('DOMContentLoaded', function() {\n    \/\/ Fonction g\u00e9n\u00e9rique pour g\u00e9rer la visibilit\u00e9 d'une date en fonction des boutons radio\n    function toggleDateVisibility(radioYes, radioNo, dateContainer) {\n        if (radioYes.checked) {\n            dateContainer.style.display = 'block';  \/\/ Affiche le champ si \"Oui\" est coch\u00e9\n        } else {\n            dateContainer.style.display = 'none';   \/\/ Cache le champ si \"Non\" est coch\u00e9\n        }\n    }\n\n    \/\/ Ajoute une fonction pour chaque groupe\n    function setupToggle(radioYesId, radioNoId, dateContainerId) {\n        const radioYes = document.getElementById(radioYesId);\n        const radioNo = document.getElementById(radioNoId);\n        const dateContainer = document.getElementById(dateContainerId);\n\n        \/\/ Attache les \u00e9v\u00e9nements change \u00e0 chaque radio\n        radioYes.addEventListener('change', function() {\n            toggleDateVisibility(radioYes, radioNo, dateContainer);\n        });\n        radioNo.addEventListener('change', function() {\n            toggleDateVisibility(radioYes, radioNo, dateContainer);\n        });\n\n        \/\/ Appeler la fonction au chargement pour g\u00e9rer l'\u00e9tat initial\n        toggleDateVisibility(radioYes, radioNo, dateContainer);\n    }\n\n    \/\/ Configuration pour chaque groupe (toxine botulique, acide hyaluronique, laser, peeling)\n    setupToggle('botox_oui', 'botox_non', 'botox_date_container');\n    setupToggle('hyaluronic_acid_oui', 'hyaluronic_acid_non', 'hyaluronic_acid_date_container');\n    setupToggle('laser_oui', 'laser_non', 'laser_date_container');\n    setupToggle('peeling_oui', 'peeling_non', 'peeling_date_container');\n});\n function checkProtection(checkbox) {\n            if (checkbox.checked) {\n                \/\/ Si la case est coch\u00e9e, afficher le message et d\u00e9sactiver le reste du formulaire\n                document.getElementById(\"message\").style.display = \"block\";\n                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