<style id="elementor-post-44">.elementor-44 .elementor-element.elementor-element-657d40f{--display:flex;--min-height:712px;--flex-direction:column;--container-widget-width:100%;--container-widget-height:initial;--container-widget-flex-grow:0;--container-widget-align-self:initial;--flex-wrap-mobile:wrap;--justify-content:center;--overlay-opacity:0.35;--margin-top:0px;--margin-bottom:0px;--margin-left:0px;--margin-right:0px;--padding-top:0px;--padding-bottom:0px;--padding-left:30px;--padding-right:30px;}.elementor-44 .elementor-element.elementor-element-657d40f:not(.elementor-motion-effects-element-type-background), .elementor-44 .elementor-element.elementor-element-657d40f > .elementor-motion-effects-container > .elementor-motion-effects-layer{background-image:url("https://fieldtriphealth.ca/wp-content/uploads/2023/11/FT-LA-2.jpg");background-position:center center;background-repeat:no-repeat;background-size:cover;}.elementor-44 .elementor-element.elementor-element-657d40f::before, .elementor-44 .elementor-element.elementor-element-657d40f > .elementor-background-video-container::before, .elementor-44 .elementor-element.elementor-element-657d40f > .e-con-inner > .elementor-background-video-container::before, .elementor-44 .elementor-element.elementor-element-657d40f > .elementor-background-slideshow::before, .elementor-44 .elementor-element.elementor-element-657d40f > .e-con-inner > .elementor-background-slideshow::before, .elementor-44 .elementor-element.elementor-element-657d40f > .elementor-motion-effects-container > .elementor-motion-effects-layer::before{background-color:#000000;--background-overlay:'';}.elementor-44 .elementor-element.elementor-element-0281149{--display:flex;--padding-top:0px;--padding-bottom:0px;--padding-left:0px;--padding-right:0px;}.elementor-widget-heading .elementor-heading-title{font-family:var( --e-global-typography-primary-font-family ), Sans-serif;font-weight:var( --e-global-typography-primary-font-weight );color:var( --e-global-color-primary );}.elementor-44 .elementor-element.elementor-element-40581c9{width:auto;max-width:auto;text-align:center;}.elementor-44 .elementor-element.elementor-element-40581c9 .elementor-heading-title{font-family:"Cooper BT", Sans-serif;font-size:50px;font-weight:500;line-height:75px;color:#FAFAFA;}.elementor-widget-text-editor{font-family:var( --e-global-typography-text-font-family ), Sans-serif;font-weight:var( --e-global-typography-text-font-weight );color:var( --e-global-color-text );}.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:var( --e-global-color-primary );}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap, .elementor-widget-text-editor.elementor-drop-cap-view-default .elementor-drop-cap{color:var( --e-global-color-primary );border-color:var( --e-global-color-primary );}.elementor-44 .elementor-element.elementor-element-c5da42b{text-align:center;font-family:"Sofia Pro", Sans-serif;font-size:21px;font-weight:500;line-height:31.5px;letter-spacing:-0.5px;color:#FFFFFF;}.elementor-widget-button .elementor-button{background-color:var( --e-global-color-accent );font-family:var( --e-global-typography-accent-font-family ), Sans-serif;font-weight:var( --e-global-typography-accent-font-weight );}.elementor-44 .elementor-element.elementor-element-3a04e69 .elementor-button{background-color:#FA692C;font-family:"Sofia Pro", Sans-serif;font-size:16px;font-weight:700;line-height:22px;letter-spacing:0.2px;border-radius:4px 4px 4px 4px;padding:15px 24px 15px 24px;}.elementor-44 .elementor-element.elementor-element-3a04e69 .elementor-button:hover, .elementor-44 .elementor-element.elementor-element-3a04e69 .elementor-button:focus{background-color:#CC511C;}.elementor-44 .elementor-element.elementor-element-3a04e69 > .elementor-widget-container{padding:0px 0px 80px 0px;}.elementor-44 .elementor-element.elementor-element-3ee34c0{--display:flex;--flex-direction:column;--container-widget-width:100%;--container-widget-height:initial;--container-widget-flex-grow:0;--container-widget-align-self:initial;--flex-wrap-mobile:wrap;--padding-top:0px;--padding-bottom:130px;--padding-left:95px;--padding-right:95px;}.elementor-44 .elementor-element.elementor-element-3ee34c0:not(.elementor-motion-effects-element-type-background), .elementor-44 .elementor-element.elementor-element-3ee34c0 > .elementor-motion-effects-container > .elementor-motion-effects-layer{background-color:#F3EAE5;}.elementor-44 .elementor-element.elementor-element-3ee34c0.e-con{--flex-grow:0;--flex-shrink:0;}.elementor-44 .elementor-element.elementor-element-aaff34a{--display:flex;--margin-top:-164px;--margin-bottom:0px;--margin-left:0px;--margin-right:0px;--padding-top:80px;--padding-bottom:299px;--padding-left:100px;--padding-right:100px;}.elementor-44 .elementor-element.elementor-element-aaff34a:not(.elementor-motion-effects-element-type-background), .elementor-44 .elementor-element.elementor-element-aaff34a > .elementor-motion-effects-container > .elementor-motion-effects-layer{background-color:#FFFFFF;}.elementor-44 .elementor-element.elementor-element-aaff34a.e-con{--align-self:center;}@media(max-width:1024px){.elementor-44 .elementor-element.elementor-element-657d40f{--justify-content:center;}.elementor-44 .elementor-element.elementor-element-c5da42b{font-size:16px;line-height:24px;letter-spacing:0px;}.elementor-44 .elementor-element.elementor-element-3a04e69 > .elementor-widget-container{padding:0px 0px 50px 0px;}.elementor-44 .elementor-element.elementor-element-3ee34c0{--padding-top:0px;--padding-bottom:130px;--padding-left:30px;--padding-right:30px;}.elementor-44 .elementor-element.elementor-element-aaff34a{--padding-top:60px;--padding-bottom:60px;--padding-left:30px;--padding-right:30px;}}@media(min-width:768px){.elementor-44 .elementor-element.elementor-element-657d40f{--content-width:535px;}.elementor-44 .elementor-element.elementor-element-aaff34a{--width:75%;}}@media(max-width:767px){.elementor-44 .elementor-element.elementor-element-657d40f{--min-height:100vh;--justify-content:center;--padding-top:0px;--padding-bottom:0px;--padding-left:20px;--padding-right:20px;}.elementor-44 .elementor-element.elementor-element-40581c9{text-align:center;}.elementor-44 .elementor-element.elementor-element-40581c9 .elementor-heading-title{font-size:50px;}.elementor-44 .elementor-element.elementor-element-c5da42b{letter-spacing:0px;}.elementor-44 .elementor-element.elementor-element-3a04e69 > .elementor-widget-container{padding:0px 0px 0px 0px;}.elementor-44 .elementor-element.elementor-element-3ee34c0{--padding-top:0px;--padding-bottom:0px;--padding-left:20px;--padding-right:20px;}.elementor-44 .elementor-element.elementor-element-aaff34a{--margin-top:-100px;--margin-bottom:0px;--margin-left:0px;--margin-right:0px;--padding-top:30px;--padding-bottom:30px;--padding-left:20px;--padding-right:20px;}}/* Start Custom Fonts CSS */@font-face {
	font-family: 'Cooper BT';
	font-style: normal;
	font-weight: 700;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/CooperBoldBT1.ttf') format('truetype');
}
@font-face {
	font-family: 'Cooper BT';
	font-style: normal;
	font-weight: 300;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/CooperLightBT2.ttf') format('truetype');
}
@font-face {
	font-family: 'Cooper BT';
	font-style: normal;
	font-weight: 500;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/Cooper-Medium-BT3.ttf') format('truetype');
}
/* End Custom Fonts CSS */
/* Start Custom Fonts CSS */@font-face {
	font-family: 'Sofia Pro';
	font-style: normal;
	font-weight: 300;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/sofiapro-light.ttf') format('truetype');
}
@font-face {
	font-family: 'Sofia Pro';
	font-style: normal;
	font-weight: 400;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/Sofia-Pro-Soft-W01-Regular.ttf') format('truetype');
}
@font-face {
	font-family: 'Sofia Pro';
	font-style: normal;
	font-weight: 500;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/SofiaProMedium.ttf') format('truetype');
}
@font-face {
	font-family: 'Sofia Pro';
	font-style: normal;
	font-weight: 600;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/SofiaProSemiBold.ttf') format('truetype');
}
@font-face {
	font-family: 'Sofia Pro';
	font-style: normal;
	font-weight: 700;
	font-display: auto;
	src: url('https://fieldtriphealth.ca/wp-content/uploads/2023/11/Sofia-Pro-Bold.ttf') format('truetype');
}
/* End Custom Fonts CSS */</style>{"id":44,"date":"2023-11-05T05:01:18","date_gmt":"2023-11-05T05:01:18","guid":{"rendered":"http:\/\/fieldtriphealth.ca\/?page_id=44"},"modified":"2026-04-23T10:41:07","modified_gmt":"2026-04-23T14:41:07","slug":"envoyer-une-recommandation","status":"publish","type":"page","link":"https:\/\/fieldtriphealth.ca\/fr\/send-a-referral\/","title":{"rendered":"Renvois"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"44\" class=\"elementor elementor-44\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-657d40f e-flex e-con-boxed e-con e-parent\" data-id=\"657d40f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-0281149 e-con-full e-flex e-con e-child\" data-id=\"0281149\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-40581c9 elementor-widget__width-auto elementor-widget elementor-widget-heading\" data-id=\"40581c9\" 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<h1 class=\"elementor-heading-title elementor-size-default\">Envoyer une recommandation.<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c5da42b elementor-widget elementor-widget-text-editor\" data-id=\"c5da42b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"policy_section\">\n<header class=\"header header--referral\">\n<div class=\"container header-container header-container--referral\">\n<p class=\"header_text header_text--referral\">Si vous \u00eates m\u00e9decin ou professionnel de la sant\u00e9 et que vous souhaitez r\u00e9f\u00e9rer un patient au programme de th\u00e9rapie assist\u00e9e par psych\u00e9d\u00e9liques de Field Trip Health, veuillez soumettre ses informations ici via notre formulaire de r\u00e9f\u00e9rence s\u00e9curis\u00e9.<\/p>\n<p>Les r\u00e9f\u00e9rences peuvent \u00e9galement \u00eatre soumises via le r\u00e9seau Ocean eReferral.<\/p>\n<\/div>\n<\/header>\n<\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3a04e69 elementor-align-center elementor-widget elementor-widget-button\" data-id=\"3a04e69\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/fieldtriphealth.ca\/wp-content\/uploads\/2026\/03\/Field-Trip-Health-Client-Referral-Form-2026.pdf\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">T\u00e9l\u00e9charger le formulaire de recommandation<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\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-3ee34c0 e-con-full e-flex e-con e-parent\" data-id=\"3ee34c0\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-aaff34a e-con-full focus_110 e-flex e-con e-child\" data-id=\"aaff34a\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-215426a elementor-widget elementor-widget-shortcode\" data-id=\"215426a\" 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\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-5118 forminator-design--material  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-5118\" data-uid=\"6ac845ea2dfd6\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-5118\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-5118 forminator-design--material  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"5118\"\r\n\t\t\t\t data-color-option=\"default\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6ac845ea2dfd6\" action=\"\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Informations pour les patients<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_6ac845ea2dfd6\" id=\"forminator-field-first-name-1_6ac845ea2dfd6-label\" class=\"forminator-label\">Pr\u00e9nom du patient <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"Par exemple, John\" id=\"forminator-field-first-name-1_6ac845ea2dfd6\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_6ac845ea2dfd6\" id=\"forminator-field-last-name-1_6ac845ea2dfd6-label\" class=\"forminator-label\">Nom du patient <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"Par exemple, Doe\" id=\"forminator-field-last-name-1_6ac845ea2dfd6\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12\"><label for=\"forminator-field-date-1\" id=\"forminator-field-date-1-label\" class=\"forminator-label\">Date de naissance <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-1-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-5118__field--date-1-month_6ac845ea2dfd6\" id=\"forminator-field-5118__field--date-1-month_6ac845ea2dfd6-label\" class=\"forminator-label\">Mois<\/label><select name=\"date-1-month\" id=\"forminator-field-5118__field--date-1-month_6ac845ea2dfd6\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-5118__field--date-1-month_6ac845ea2dfd6-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le mois<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-1-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-5118__field--date-1-day_6ac845ea2dfd6\" id=\"forminator-field-5118__field--date-1-day_6ac845ea2dfd6-label\" class=\"forminator-label\">Jour<\/label><select name=\"date-1-day\" id=\"forminator-field-5118__field--date-1-day_6ac845ea2dfd6\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-5118__field--date-1-day_6ac845ea2dfd6-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le jour<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-1-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-5118__field--date-1-year_6ac845ea2dfd6\" id=\"forminator-field-5118__field--date-1-year_6ac845ea2dfd6-label\" class=\"forminator-label\">Ann\u00e9e<\/label><select name=\"date-1-year\" id=\"forminator-field-5118__field--date-1-year_6ac845ea2dfd6\" class=\"forminator-select2\" data-format=\"mm\/dd\/yy\" data-parent=\"date-1\" aria-labelledby=\"forminator-field-5118__field--date-1-year_6ac845ea2dfd6-label\" data-default-value=\"2026\"><option value=\"\" >S\u00e9lectionner l'ann\u00e9e<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-form-5118__field--select-1_6ac845ea2dfd6\" id=\"forminator-form-5118__field--select-1_6ac845ea2dfd6-label\" class=\"forminator-label\">Sexe <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-5118__field--select-1_6ac845ea2dfd6\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Please select\" data-search=\"false\" data-search-placeholder=\"Please select\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-5118__field--select-1_6ac845ea2dfd6-label\"><option value=\"\"  >Veuillez s\u00e9lectionner<\/option><option value=\"one\"  data-calculation=\"0\">Homme<\/option><option value=\"two\"  data-calculation=\"0\">Femme<\/option><option value=\"Other\"  data-calculation=\"0\">Autres<\/option><\/select><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6ac845ea2dfd6\" id=\"forminator-field-text-3_6ac845ea2dfd6-label\" class=\"forminator-label\">Num\u00e9ro de carte sant\u00e9 et code de version <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"1234 567 890 AB\" id=\"forminator-field-text-3_6ac845ea2dfd6\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6ac845ea2dfd6\" id=\"forminator-field-email-1_6ac845ea2dfd6-label\" class=\"forminator-label\">Adresse \u00e9lectronique <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"Par exemple : john@doe.com\" id=\"forminator-field-email-1_6ac845ea2dfd6\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6ac845ea2dfd6\" id=\"forminator-field-phone-1_6ac845ea2dfd6-label\" class=\"forminator-label\">T\u00e9l\u00e9phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"Par exemple : +1 300 400 5000\" id=\"forminator-field-phone-1_6ac845ea2dfd6\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_6ac845ea2dfd6\" id=\"forminator-field-address-2-street_address_6ac845ea2dfd6-label\" class=\"forminator-label\">Adresse<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"\" id=\"forminator-field-address-2-street_address_6ac845ea2dfd6\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-5118__field--select-2_6ac845ea2dfd6\" id=\"forminator-form-5118__field--select-2_6ac845ea2dfd6-label\" class=\"forminator-label\">S\u00e9lectionnez le lieu de la clinique <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-5118__field--select-2_6ac845ea2dfd6\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Select Clinic Location\" data-search=\"false\" data-search-placeholder=\"Select Clinic Location\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-5118__field--select-2_6ac845ea2dfd6-label\"><option value=\"\"  >S\u00e9lectionnez le lieu de la clinique<\/option><option value=\"Toronto\"  data-calculation=\"0\">Toronto<\/option><option value=\"Montreal\"  data-calculation=\"0\">Montr\u00e9al<\/option><option value=\"Vancouver\"  data-calculation=\"0\">Vancouver<\/option><option value=\"Ottawa\"  data-calculation=\"0\">Ottawa<\/option><option value=\"Hamilton\"  data-calculation=\"0\">Hamilton<\/option><option value=\"Kitchener-Waterloo\"  data-calculation=\"0\">Kitchener Waterloo<\/option><option value=\"Thunder Bay\"  data-calculation=\"0\">Thunder Bay<\/option><option value=\"Sault Ste. Marie\"  data-calculation=\"0\">Sault Ste. Marie<\/option><option value=\"Winnipeg\"  data-calculation=\"0\">Winnipeg<\/option><option value=\"Other---At-Home\"  data-calculation=\"0\">Autre - A domicile<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Informations sur le m\u00e9decin r\u00e9f\u00e9rent<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-2_6ac845ea2dfd6\" id=\"forminator-field-first-name-2_6ac845ea2dfd6-label\" class=\"forminator-label\">Pr\u00e9nom du prestataire <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2-first-name\" placeholder=\"Par exemple, John\" id=\"forminator-field-first-name-2_6ac845ea2dfd6\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-2_6ac845ea2dfd6\" id=\"forminator-field-last-name-2_6ac845ea2dfd6-label\" class=\"forminator-label\">Nom de famille du prestataire<\/label><input type=\"text\" name=\"name-2-last-name\" placeholder=\"Par exemple, Doe\" id=\"forminator-field-last-name-2_6ac845ea2dfd6\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_6ac845ea2dfd6\" id=\"forminator-field-email-2_6ac845ea2dfd6-label\" class=\"forminator-label\">Adresse \u00e9lectronique <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"Par exemple : john@doe.com\" id=\"forminator-field-email-2_6ac845ea2dfd6\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6ac845ea2dfd6\" id=\"forminator-field-phone-2_6ac845ea2dfd6-label\" class=\"forminator-label\">T\u00e9l\u00e9phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"Par exemple : +1 300 400 5000\" id=\"forminator-field-phone-2_6ac845ea2dfd6\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6ac845ea2dfd6\" id=\"forminator-field-text-1_6ac845ea2dfd6-label\" class=\"forminator-label\">Num\u00e9ro de fax <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"Num\u00e9ro de fax\" id=\"forminator-field-text-1_6ac845ea2dfd6\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6ac845ea2dfd6\" id=\"forminator-field-text-2_6ac845ea2dfd6-label\" class=\"forminator-label\">Nom de la pratique <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"Nom de la pratique\" id=\"forminator-field-text-2_6ac845ea2dfd6\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Adresse du cabinet<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6ac845ea2dfd6\" id=\"forminator-field-address-1-street_address_6ac845ea2dfd6-label\" class=\"forminator-label\">Adresse (rue) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"Par exemple, 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_6ac845ea2dfd6\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6ac845ea2dfd6\" id=\"forminator-field-address-1-address_line_6ac845ea2dfd6-label\" class=\"forminator-label\">Appartement, suite, etc.<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6ac845ea2dfd6\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6ac845ea2dfd6\" id=\"forminator-field-address-1-city_6ac845ea2dfd6-label\" class=\"forminator-label\">Ville<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"Par exemple, Sydney\" id=\"forminator-field-address-1-city_6ac845ea2dfd6\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6ac845ea2dfd6\" id=\"forminator-field-address-1-state_6ac845ea2dfd6-label\" class=\"forminator-label\">\u00c9tat\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"Par exemple, la Nouvelle-Galles du Sud\" id=\"forminator-field-address-1-state_6ac845ea2dfd6\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6ac845ea2dfd6\" id=\"forminator-field-address-1-zip_6ac845ea2dfd6-label\" class=\"forminator-label\">Code postal<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"Par exemple, en 2000\" id=\"forminator-field-address-1-zip_6ac845ea2dfd6\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-5118__field--address-1-country_6ac845ea2dfd6\" id=\"forminator-field-5118__field--address-1-country_6ac845ea2dfd6-label\" class=\"forminator-label\">Pays<\/label><select name=\"address-1-country\" id=\"forminator-field-5118__field--address-1-country_6ac845ea2dfd6\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" autocomplete=\"country-name\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albanie<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Alg\u00e9rie<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorre<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctique<\/option><option value=\"Antigua &amp; Barbuda\" data-country-code=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentine<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Arm\u00e9nie<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Ascension Island\" data-country-code=\"AC\" >L'\u00cele de l'Ascension<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australie<\/option><option value=\"Austria\" data-country-code=\"AT\" >Autriche<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahre\u00efn<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbade<\/option><option value=\"Belarus\" data-country-code=\"BY\" >B\u00e9larus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgique<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >B\u00e9nin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermudes<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhoutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivie<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnie et Herz\u00e9govine<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >\u00cele Bouvet<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Br\u00e9sil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >Territoire britannique de l'oc\u00e9an Indien<\/option><option value=\"British Virgin Islands\" data-country-code=\"VG\" >\u00celes vierges britanniques<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgarie<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodge<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroun<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Caribbean Netherlands\" data-country-code=\"BQ\" >Antilles n\u00e9erlandaises<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >R\u00e9publique centrafricaine<\/option><option value=\"Chad\" data-country-code=\"TD\" >Tchad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chili<\/option><option value=\"China\" data-country-code=\"CN\" >Chine<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >L'\u00eele de No\u00ebl<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >\u00celes Cocos<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombie<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comores<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, R\u00e9publique d\u00e9mocratique du<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, R\u00e9publique du<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >\u00celes Cook<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatie<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Chypre<\/option><option value=\"Czechia\" data-country-code=\"CZ\" >Tch\u00e9quie<\/option><option value=\"C\u00f4te d&#039;Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Danemark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominique<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >R\u00e9publique dominicaine<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >\u00c9quateur<\/option><option value=\"Egypt\" data-country-code=\"EG\" >\u00c9gypte<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Guin\u00e9e \u00e9quatoriale<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Erythr\u00e9e<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonie<\/option><option value=\"Eswatini\" data-country-code=\"SZ\" >Eswatini<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >\u00c9thiopie<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >\u00celes Malouines<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fidji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finlande<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >Guyane fran\u00e7aise<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >Polyn\u00e9sie fran\u00e7aise<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >Territoires fran\u00e7ais du Sud<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambie<\/option><option value=\"Georgia\" data-country-code=\"GE\" >G\u00e9orgie<\/option><option value=\"Germany\" data-country-code=\"DE\" >Allemagne<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Gr\u00e8ce<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Groenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenade<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernesey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guin\u00e9e<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyane<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Ha\u00efti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >\u00cele Heard et \u00eele Mcdonald<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong SAR China\" data-country-code=\"HK\" >RAS de Hong Kong Chine<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hongrie<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Islande<\/option><option value=\"India\" data-country-code=\"IN\" >Inde<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indon\u00e9sie<\/option><option value=\"Iran\" data-country-code=\"IR\" >L'Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >L'Irak<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Irlande<\/option><option value=\"Isle of Man\" data-country-code=\"IM\" >\u00cele de Man<\/option><option value=\"Israel\" data-country-code=\"IL\" >Isra\u00ebl<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italie<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jama\u00efque<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japon<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordanie<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kowe\u00eft<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kirghizistan<\/option><option value=\"Lao People&#039;s Democratic Republic\" data-country-code=\"LA\" >R\u00e9publique d\u00e9mocratique populaire lao<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Lettonie<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Liban<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Lib\u00e9ria<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libye<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lituanie<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao SAR China\" data-country-code=\"MO\" >Macao RAS Chine<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaisie<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malte<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >\u00celes Marshall<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritanie<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Maurice<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexique<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micron\u00e9sie<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldavie<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolie<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Maroc<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibie<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >N\u00e9pal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Pays-Bas<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >Nouvelle-Z\u00e9lande<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nig\u00e9ria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >\u00cele Norfolk<\/option><option value=\"North Korea\" data-country-code=\"KP\" >Cor\u00e9e du Nord<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >Mac\u00e9doine du Nord<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Mariannes du Nord (\u00celes)<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norv\u00e8ge<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestinian Territories\" data-country-code=\"PS\" >Territoires palestiniens<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >P\u00e9rou<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn (\u00celes)<\/option><option value=\"Poland\" data-country-code=\"PL\" >Pologne<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Porto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Romania\" data-country-code=\"RO\" >Roumanie<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russie<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"R\u00e9union\" data-country-code=\"RE\" >R\u00e9union<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Sainte-H\u00e9l\u00e8ne<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint-Kitts-et-Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Sainte-Lucie<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >Saint-Marin<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Arabie Saoudite<\/option><option value=\"Senegal\" data-country-code=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbie<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapour<\/option><option value=\"Sint Maarten\" data-country-code=\"SX\" >Saint-Martin<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovaquie<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slov\u00e9nie<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >\u00celes Salomon<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalie<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >Afrique du Sud<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >G\u00e9orgie du Sud et Sandwich du Sud<\/option><option value=\"South Korea\" data-country-code=\"KR\" >Cor\u00e9e du Sud<\/option><option value=\"South Sudan\" data-country-code=\"SS\" >Soudan du Sud<\/option><option value=\"Spain\" data-country-code=\"ES\" >Espagne<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"St. Barth\u00e9lemy\" data-country-code=\"BL\" >Saint-Barth\u00e9lemy<\/option><option value=\"St. Martin\" data-country-code=\"MF\" >Saint-Martin<\/option><option value=\"St. Pierre &amp; Miquelon\" data-country-code=\"PM\" >Saint-Pierre-et-Miquelon<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Soudan<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard et Jan Mayen<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Su\u00e8de<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Suisse<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syrie<\/option><option value=\"S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe\" data-country-code=\"ST\" >Sao Tom\u00e9-et-Principe<\/option><option value=\"Taiwan\" data-country-code=\"TW\" >Ta\u00efwan<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tadjikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzanie<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Tha\u00eflande<\/option><option value=\"Timor-Leste\" data-country-code=\"TL\" >Timor-Leste<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad &amp; Tobago\" data-country-code=\"TT\" >Trinit\u00e9-et-Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisie<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turquie<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"Turks &amp; Caicos Islands\" data-country-code=\"TC\" >\u00celes Turques-et-Ca\u00efques<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"U.S. Virgin Islands\" data-country-code=\"VI\" >\u00celes Vierges des \u00c9tats-Unis<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Ouganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >\u00c9mirats arabes unis<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >Royaume-Uni<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >\u00c9tats-Unis d'Am\u00e9rique (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Cit\u00e9 du Vatican<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis et Futuna (\u00celes)<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Sahara occidental<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Y\u00e9men<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambie<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Motif de la saisine<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6ac845ea2dfd6\" id=\"forminator-field-textarea-1_6ac845ea2dfd6-label\" class=\"forminator-label\">Veuillez fournir des informations cliniques pertinentes, telles que le diagnostic du patient, les ant\u00e9c\u00e9dents th\u00e9rapeutiques\/les essais de m\u00e9dicaments, etc.<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6ac845ea2dfd6\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\"><span>Envoyer une recommandation<\/span><span aria-hidden=\"true\"><\/span><\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"c4bdde20f3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/44\" \/><input type=\"hidden\" name=\"form_id\" value=\"5118\"><input type=\"hidden\" name=\"page_id\" value=\"44\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/fieldtriphealth.ca\/fr\/send-a-referral\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/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<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Envoyez une r\u00e9f\u00e9rence. Si vous \u00eates un m\u00e9decin ou un professionnel de la sant\u00e9 et que vous souhaitez r\u00e9f\u00e9rer un patient au programme de th\u00e9rapie assist\u00e9e par psych\u00e9d\u00e9liques de Field Trip Health, veuillez soumettre ses informations ici via notre formulaire de r\u00e9f\u00e9rence s\u00e9curis\u00e9. Les r\u00e9f\u00e9rences peuvent \u00e9galement \u00eatre soumises via le r\u00e9seau Ocean eReferral. T\u00e9l\u00e9charger le formulaire de r\u00e9f\u00e9rence<\/p>","protected":false},"author":26,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"content-type":"","inline_featured_image":false,"footnotes":""},"class_list":["post-44","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v28.6 (Yoast SEO v28.6) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Referrals - Field Trip Health<\/title>\n<meta name=\"description\" content=\"Refer your patients to Field Trip Health&#039;s psychedelic-assisted therapy program with our secure referral form.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/fieldtriphealth.ca\/fr\/envoyer-une-recommandation\/\" \/>\n<meta property=\"og:locale\" content=\"fr_CA\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Referrals\" \/>\n<meta property=\"og:description\" content=\"Refer your patients to Field Trip Health&#039;s psychedelic-assisted therapy program with our secure referral form.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/fieldtriphealth.ca\/fr\/envoyer-une-recommandation\/\" \/>\n<meta property=\"og:site_name\" content=\"Field Trip Health\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/fieldtriphealthcanada\" \/>\n<meta property=\"article:modified_time\" content=\"2026-04-23T14:41:07+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:site\" content=\"@fieldtriphealth\" \/>\n<meta name=\"twitter:label1\" content=\"Estimation du temps de lecture\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/fieldtriphealth.ca\\\/send-a-referral\\\/\",\"url\":\"https:\\\/\\\/fieldtriphealth.ca\\\/send-a-referral\\\/\",\"name\":\"Referrals - 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