{"id":4546,"date":"2020-08-26T18:10:39","date_gmt":"2020-08-26T18:10:39","guid":{"rendered":"https:\/\/perioclinik.ca\/referrals\/"},"modified":"2025-07-25T15:36:49","modified_gmt":"2025-07-25T15:36:49","slug":"references","status":"publish","type":"page","link":"https:\/\/perioclinik.ca\/fr\/references\/","title":{"rendered":"R\u00e9f\u00e9rences"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row full_width=\u00a0\u00bbstretch_row_content\u00a0\u00bb background_attachment=\u00a0\u00bbfixed\u00a0\u00bb lg_spacing=\u00a0\u00bbpadding_top:90;padding_bottom:90&Prime; background_image=\u00a0\u00bb4704&Prime; background_position=\u00a0\u00bbcenter\u00a0\u00bb el_class=\u00a0\u00bbref-form-parent\u00a0\u00bb][vc_column width=\u00a0\u00bb1\/4&Prime; sm_content_alignment=\u00a0\u00bbcenter\u00a0\u00bb offset=\u00a0\u00bbvc_col-lg-offset-6 vc_col-lg-6&Prime; lg_spacing=\u00a0\u00bbmargin_right:100&Prime; md_spacing=\u00a0\u00bbmargin_right:90&Prime; sm_spacing=\u00a0\u00bbmargin_right:0&Prime; xs_spacing=\u00a0\u00bbmargin_right:0&Prime; el_class=\u00a0\u00bbconsult\u00a0\u00bb][vc_row_inner background_color=\u00a0\u00bbcustom\u00a0\u00bb lg_spacing=\u00a0\u00bbmargin_right:0;margin_left:0;padding_top:50;padding_right:35;padding_bottom:50;padding_left:35&Prime; custom_background_color=\u00a0\u00bb#ffffff\u00a0\u00bb sm_spacing=\u00a0\u00bbpadding_top:30;padding_right:15;padding_bottom:30;padding_left:15&Prime;][vc_column_inner el_class=\u00a0\u00bbref-form\u00a0\u00bb offset=\u00a0\u00bbvc_col-md-12 vc_col-sm-offset-0 vc_col-xs-12&Prime;][tm_heading tag=\u00a0\u00bbh1&Prime; custom_google_font=\u00a0\u00bb\u00a0\u00bb google_fonts=\u00a0\u00bbfont_family:Poppins%3A300%2Cregular%2C500%2C600%2C700|font_style:300%20light%20regular%3A300%3Anormal\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbR\u00e9f\u00e9rence de patient\u00a0\u00bb font_size=\u00a0\u00bblg:36&Prime;][tm_spacer size=\u00a0\u00bblg:15&Prime;][tm_heading tag=\u00a0\u00bbdiv\u00a0\u00bb custom_google_font=\u00a0\u00bb\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbRemplissez le formulaire ci-dessous pour orienter un patient vers la PerioClinik. Nous avons h\u00e2te de discuter avec vous de votre patient.\u00a0\u00bb max_width=\u00a0\u00bb406px\u00a0\u00bb][tm_spacer size=\u00a0\u00bblg:40&Prime;][vc_column_text css=\u00a0\u00bb\u00a0\u00bb]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4696-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"4696\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/fr\/wp-json\/wp\/v2\/pages\/4546#wpcf7-f4696-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"4696\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.4\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4696-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"section\">\n\t<p><span class=\"section-title\">1- Informations du r\u00e9f\u00e9rent:<\/span><br \/>\n<label for=\"referent-nom\">Nom et pr\u00e9nom<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"referent-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referent-nom\" \/><\/span>\n\t<\/p>\n\t<div class=\"wrap\">\n\t\t<p><span><label for=\"referent-tel\">Tel<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"referent-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"referent-tel\" \/><\/span><\/span><br \/>\n<span><label for=\"referent-email\">Courriel<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"referent-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"referent-email\" \/><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"section\">\n\t<p><span class=\"section-title\">2- Informations du patient:<\/span>\n\t<\/p>\n\t<div class=\"wrap\">\n\t\t<p><span><label for=\"patient-nom\">Nom et pr\u00e9nom<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"patient-nom\" \/><\/span><\/span><br \/>\n<span><label for=\"patient-dob\">Date de naissance<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"patient-dob\" \/><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"wrap\">\n\t\t<p><span><label for=\"patient-tel\">Tel<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"patient-tel\" \/><\/span><\/span><br \/>\n<span><label for=\"patient-email\">Courriel<\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"patient-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"patient-email\" \/><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"section section-motif\">\n\t<p><span class=\"section-title\">3- Motif de la r\u00e9f\u00e9rence:<\/span><br \/>\n<label>Choisissez les motifs<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"motif-ref\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Examen parodontal complet\" \/><span class=\"wpcf7-list-item-label\">Examen parodontal complet<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Examen pr\u00e9 orthodontique\" \/><span class=\"wpcf7-list-item-label\">Examen pr\u00e9 orthodontique<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Greffe de gencive\" \/><span class=\"wpcf7-list-item-label\">Greffe de gencive<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Greffe osseuse\" \/><span class=\"wpcf7-list-item-label\">Greffe osseuse<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Implant dentaire\" \/><span class=\"wpcf7-list-item-label\">Implant dentaire<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Extractions\" \/><span class=\"wpcf7-list-item-label\">Extractions<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Allongement de couronne clinique\" \/><span class=\"wpcf7-list-item-label\">Allongement de couronne clinique<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Exposition chirurgicale de dent incluse\" \/><span class=\"wpcf7-list-item-label\">Exposition chirurgicale de dent incluse<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Traitement parodontite\" \/><span class=\"wpcf7-list-item-label\">Traitement parodontite<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Traitement p\u00e9ri-implantite\" \/><span class=\"wpcf7-list-item-label\">Traitement p\u00e9ri-implantite<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"S\u00e9dation\" \/><span class=\"wpcf7-list-item-label\">S\u00e9dation<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Radio 3D\" \/><span class=\"wpcf7-list-item-label\">Radio 3D<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"M\u00e9decine \/ pathologie buccale\" \/><span class=\"wpcf7-list-item-label\">M\u00e9decine \/ pathologie buccale<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"motif-ref[]\" value=\"Autres\" \/><span class=\"wpcf7-list-item-label\">Autres<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"section section-dents\">\n\t<div class=\"form-question\">\n\t\t<p><span class=\"section-title\">4- Cocher les num\u00e9ros des dents concern\u00e9es:<\/span><br \/>\n<label>Choisissez les dents concern\u00e9es<\/label>\n\t\t<\/p>\n \n <!-- Premier groupe -->\n\t\t<div class=\"dents-group\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dents\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"dents[]\" value=\"18\" \/><span class=\"wpcf7-list-item-label\">18<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"17\" \/><span class=\"wpcf7-list-item-label\">17<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"16\" \/><span class=\"wpcf7-list-item-label\">16<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"15\" \/><span class=\"wpcf7-list-item-label\">15<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"14\" \/><span class=\"wpcf7-list-item-label\">14<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"13\" \/><span class=\"wpcf7-list-item-label\">13<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"21\" \/><span class=\"wpcf7-list-item-label\">21<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"22\" \/><span class=\"wpcf7-list-item-label\">22<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"23\" \/><span class=\"wpcf7-list-item-label\">23<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"24\" \/><span class=\"wpcf7-list-item-label\">24<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"25\" \/><span class=\"wpcf7-list-item-label\">25<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"26\" \/><span class=\"wpcf7-list-item-label\">26<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"27\" \/><span class=\"wpcf7-list-item-label\">27<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"28\" \/><span class=\"wpcf7-list-item-label\">28<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"48\" \/><span class=\"wpcf7-list-item-label\">48<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"47\" \/><span class=\"wpcf7-list-item-label\">47<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"46\" \/><span class=\"wpcf7-list-item-label\">46<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"45\" \/><span class=\"wpcf7-list-item-label\">45<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"44\" \/><span class=\"wpcf7-list-item-label\">44<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"43\" \/><span class=\"wpcf7-list-item-label\">43<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"42\" \/><span class=\"wpcf7-list-item-label\">42<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"41\" \/><span class=\"wpcf7-list-item-label\">41<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"31\" \/><span class=\"wpcf7-list-item-label\">31<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"32\" \/><span class=\"wpcf7-list-item-label\">32<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"33\" \/><span class=\"wpcf7-list-item-label\">33<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"34\" \/><span class=\"wpcf7-list-item-label\">34<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"35\" \/><span class=\"wpcf7-list-item-label\">35<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"36\" \/><span class=\"wpcf7-list-item-label\">36<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"37\" \/><span class=\"wpcf7-list-item-label\">37<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"dents[]\" value=\"38\" \/><span class=\"wpcf7-list-item-label\">38<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\n <!-- Deuxi\u00e8me groupe -->\n\t\t<div class=\"dents-group\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"dents\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"dents[]\" value=\"55\" \/><span class=\"wpcf7-list-item-label\">55<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"54\" \/><span class=\"wpcf7-list-item-label\">54<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"53\" \/><span class=\"wpcf7-list-item-label\">53<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"52\" \/><span class=\"wpcf7-list-item-label\">52<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"51\" \/><span class=\"wpcf7-list-item-label\">51<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"61\" \/><span class=\"wpcf7-list-item-label\">61<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"62\" \/><span class=\"wpcf7-list-item-label\">62<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"63\" \/><span class=\"wpcf7-list-item-label\">63<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"64\" \/><span class=\"wpcf7-list-item-label\">64<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"65\" \/><span class=\"wpcf7-list-item-label\">65<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"85\" \/><span class=\"wpcf7-list-item-label\">85<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"84\" \/><span class=\"wpcf7-list-item-label\">84<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"83\" \/><span class=\"wpcf7-list-item-label\">83<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"82\" \/><span class=\"wpcf7-list-item-label\">82<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"81\" \/><span class=\"wpcf7-list-item-label\">81<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"71\" \/><span class=\"wpcf7-list-item-label\">71<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"72\" \/><span class=\"wpcf7-list-item-label\">72<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"73\" \/><span class=\"wpcf7-list-item-label\">73<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"dents[]\" value=\"74\" \/><span class=\"wpcf7-list-item-label\">74<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"dents[]\" value=\"75\" \/><span class=\"wpcf7-list-item-label\">75<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"section\">\n\t<p><span class=\"section-title\">5- Joindre images \/ radiographies ou documents (png, jpeg, PDF...):<\/span><br \/>\n<div id=\"mfcf7_zl_multifilecontainer\"><span class=\"mfcf7-zl-multiline-sample\" style=\"display:none\"><p class=\"wpcf7-form-control-wrap multilinefile-606\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multilinefile\" multiple=\"multiple\" value=\"Ins\u00e9rer des fichiers\" aria-invalid=\"false\" type=\"file\" name=\"multilinefile-606[]\" \/> <span class=\"mfcf7-zl-multifile-name\"><\/span><a href=\"javascript:void(0);\" class=\"mfcf7_zl_delete_file\"><span class=\"delete-file\" aria-hidden=\"true\">&#x274C;<\/span><\/a><\/p><\/span><\/div><span class=\"wpcf7-form-control-wrap zl-form-control-wrap multilinefile-606\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multilinefile\" multiple=\"multiple\" value=\"Ins\u00e9rer des fichiers\" aria-invalid=\"false\" type=\"file\" name=\"multilinefile-606[]\" \/> <span class=\"mfcf7-zl-multifile-name\"><\/span><a href=\"javascript:void(0);\" class=\"mfcf7_zl_delete_file\"><span class=\"delete-file\" aria-hidden=\"true\">&#x274C;<\/span><\/a><\/span><p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"multilinefile-606-zl-mfcf7-upld-btn\"><input type=\"button\" name=\"multilinefile-606-zl-mfcf7-upld-btn\" class=\"button button-primary qbutton\" id=\"mfcf7_zl_add_file\" value=\"Ins\u00e9rer des fichiers\"><\/span><\/label><\/p>\n\t<\/p>\n<\/div>\n<div class=\"section\">\n\t<p><span class=\"section-title\">6- Commentaires \/ instructions particuli\u00e8res:<\/span><br \/>\n<label for=\"commentaires\">Commentaires<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"commentaires\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"commentaires\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column_text][tm_spacer size=\u00a0\u00bblg:15&Prime;][vc_btn title=\u00a0\u00bbT\u00e9l\u00e9charger le formulaire de r\u00e9f\u00e9rence \u00e0 envoyer par t\u00e9l\u00e9copieur ou par courriel. Fax : 819-201-8615&Prime; style=\u00a0\u00bbflat\u00a0\u00bb shape=\u00a0\u00bbsquare\u00a0\u00bb color=\u00a0\u00bbblack\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb i_icon_fontawesome=\u00a0\u00bbfas fa-cloud-download-alt\u00a0\u00bb css=\u00a0\u00bb\u00a0\u00bb add_icon=\u00a0\u00bbtrue\u00a0\u00bb link=\u00a0\u00bburl:%2Fwp-content%2Fuploads%2F2018%2F10%2FFormulaire-de-reference-Perioclinik.pdf||target:%20_blank|\u00a0\u00bb][\/vc_column_inner][\/vc_row_inner][\/vc_column][vc_column width=\u00a0\u00bb3\/4&Prime;][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row full_width=\u00a0\u00bbstretch_row_content\u00a0\u00bb background_attachment=\u00a0\u00bbfixed\u00a0\u00bb lg_spacing=\u00a0\u00bbpadding_top:90;padding_bottom:90&Prime; background_image=\u00a0\u00bb4704&Prime; background_position=\u00a0\u00bbcenter\u00a0\u00bb el_class=\u00a0\u00bbref-form-parent\u00a0\u00bb][vc_column width=\u00a0\u00bb1\/4&Prime; sm_content_alignment=\u00a0\u00bbcenter\u00a0\u00bb offset=\u00a0\u00bbvc_col-lg-offset-6 vc_col-lg-6&Prime; lg_spacing=\u00a0\u00bbmargin_right:100&Prime; md_spacing=\u00a0\u00bbmargin_right:90&Prime; sm_spacing=\u00a0\u00bbmargin_right:0&Prime; xs_spacing=\u00a0\u00bbmargin_right:0&Prime; el_class=\u00a0\u00bbconsult\u00a0\u00bb][vc_row_inner background_color=\u00a0\u00bbcustom\u00a0\u00bb lg_spacing=\u00a0\u00bbmargin_right:0;margin_left:0;padding_top:50;padding_right:35;padding_bottom:50;padding_left:35&Prime; custom_background_color=\u00a0\u00bb#ffffff\u00a0\u00bb sm_spacing=\u00a0\u00bbpadding_top:30;padding_right:15;padding_bottom:30;padding_left:15&Prime;][vc_column_inner el_class=\u00a0\u00bbref-form\u00a0\u00bb offset=\u00a0\u00bbvc_col-md-12 vc_col-sm-offset-0 vc_col-xs-12&Prime;][tm_heading tag=\u00a0\u00bbh1&Prime; custom_google_font=\u00a0\u00bb\u00a0\u00bb google_fonts=\u00a0\u00bbfont_family:Poppins%3A300%2Cregular%2C500%2C600%2C700|font_style:300%20light%20regular%3A300%3Anormal\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbR\u00e9f\u00e9rence de patient\u00a0\u00bb font_size=\u00a0\u00bblg:36&Prime;][tm_spacer size=\u00a0\u00bblg:15&Prime;][tm_heading tag=\u00a0\u00bbdiv\u00a0\u00bb custom_google_font=\u00a0\u00bb\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbRemplissez le formulaire ci-dessous pour orienter un patient vers la PerioClinik. Nous avons h\u00e2te de discuter avec vous de votre patient.\u00a0\u00bb max_width=\u00a0\u00bb406px\u00a0\u00bb][tm_spacer size=\u00a0\u00bblg:40&Prime;][vc_column_text css=\u00a0\u00bb\u00a0\u00bb][\/vc_column_text][tm_spacer size=\u00a0\u00bblg:15&Prime;][vc_btn title=\u00a0\u00bbT\u00e9l\u00e9charger le formulaire de r\u00e9f\u00e9rence \u00e0 envoyer par t\u00e9l\u00e9copieur ou par courriel. Fax : 819-201-8615&Prime; style=\u00a0\u00bbflat\u00a0\u00bb shape=\u00a0\u00bbsquare\u00a0\u00bb color=\u00a0\u00bbblack\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb i_icon_fontawesome=\u00a0\u00bbfas fa-cloud-download-alt\u00a0\u00bb css=\u00a0\u00bb\u00a0\u00bb add_icon=\u00a0\u00bbtrue\u00a0\u00bb link=\u00a0\u00bburl:%2Fwp-content%2Fuploads%2F2018%2F10%2FFormulaire-de-reference-Perioclinik.pdf||target:%20_blank|\u00a0\u00bb][\/vc_column_inner][\/vc_row_inner][\/vc_column][vc_column width=\u00a0\u00bb3\/4&Prime;][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-4546","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.9 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>R\u00e9f\u00e9rences | PerioClinik<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/perioclinik.ca\/fr\/references\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"R\u00e9f\u00e9rences | PerioClinik\" \/>\n<meta property=\"og:description\" content=\"[vc_row full_width=\u00a0\u00bbstretch_row_content\u00a0\u00bb background_attachment=\u00a0\u00bbfixed\u00a0\u00bb lg_spacing=\u00a0\u00bbpadding_top:90;padding_bottom:90&Prime; background_image=\u00a0\u00bb4704&Prime; background_position=\u00a0\u00bbcenter\u00a0\u00bb el_class=\u00a0\u00bbref-form-parent\u00a0\u00bb][vc_column width=\u00a0\u00bb1\/4&Prime; sm_content_alignment=\u00a0\u00bbcenter\u00a0\u00bb offset=\u00a0\u00bbvc_col-lg-offset-6 vc_col-lg-6&Prime; lg_spacing=\u00a0\u00bbmargin_right:100&Prime; md_spacing=\u00a0\u00bbmargin_right:90&Prime; sm_spacing=\u00a0\u00bbmargin_right:0&Prime; xs_spacing=\u00a0\u00bbmargin_right:0&Prime; el_class=\u00a0\u00bbconsult\u00a0\u00bb][vc_row_inner background_color=\u00a0\u00bbcustom\u00a0\u00bb lg_spacing=\u00a0\u00bbmargin_right:0;margin_left:0;padding_top:50;padding_right:35;padding_bottom:50;padding_left:35&Prime; custom_background_color=\u00a0\u00bb#ffffff\u00a0\u00bb sm_spacing=\u00a0\u00bbpadding_top:30;padding_right:15;padding_bottom:30;padding_left:15&Prime;][vc_column_inner el_class=\u00a0\u00bbref-form\u00a0\u00bb offset=\u00a0\u00bbvc_col-md-12 vc_col-sm-offset-0 vc_col-xs-12&Prime;][tm_heading tag=\u00a0\u00bbh1&Prime; custom_google_font=\u00a0\u00bb\u00a0\u00bb google_fonts=\u00a0\u00bbfont_family:Poppins%3A300%2Cregular%2C500%2C600%2C700|font_style:300%20light%20regular%3A300%3Anormal\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbR\u00e9f\u00e9rence de patient\u00a0\u00bb font_size=\u00a0\u00bblg:36&Prime;][tm_spacer size=\u00a0\u00bblg:15&Prime;][tm_heading tag=\u00a0\u00bbdiv\u00a0\u00bb custom_google_font=\u00a0\u00bb\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbRemplissez le formulaire ci-dessous pour orienter un patient vers la PerioClinik. Nous avons h\u00e2te de discuter avec vous de votre patient.\u00a0\u00bb max_width=\u00a0\u00bb406px\u00a0\u00bb][tm_spacer size=\u00a0\u00bblg:40&Prime;][vc_column_text css=\u00a0\u00bb\u00a0\u00bb][\/vc_column_text][tm_spacer size=\u00a0\u00bblg:15&Prime;][vc_btn title=\u00a0\u00bbT\u00e9l\u00e9charger le formulaire de r\u00e9f\u00e9rence \u00e0 envoyer par t\u00e9l\u00e9copieur ou par courriel. Fax : 819-201-8615&Prime; style=\u00a0\u00bbflat\u00a0\u00bb shape=\u00a0\u00bbsquare\u00a0\u00bb color=\u00a0\u00bbblack\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb i_icon_fontawesome=\u00a0\u00bbfas fa-cloud-download-alt\u00a0\u00bb css=\u00a0\u00bb\u00a0\u00bb add_icon=\u00a0\u00bbtrue\u00a0\u00bb link=\u00a0\u00bburl:%2Fwp-content%2Fuploads%2F2018%2F10%2FFormulaire-de-reference-Perioclinik.pdf||target:%20_blank|\u00a0\u00bb][\/vc_column_inner][\/vc_row_inner][\/vc_column][vc_column width=\u00a0\u00bb3\/4&Prime;][\/vc_column][\/vc_row]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/perioclinik.ca\/fr\/references\/\" \/>\n<meta property=\"og:site_name\" content=\"PerioClinik\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/PerioClinikGatineau\/?locale=fr_FR\" \/>\n<meta property=\"article:modified_time\" content=\"2025-07-25T15:36:49+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\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:\/\/perioclinik.ca\/fr\/references\/\",\"url\":\"https:\/\/perioclinik.ca\/fr\/references\/\",\"name\":\"R\u00e9f\u00e9rences | PerioClinik\",\"isPartOf\":{\"@id\":\"https:\/\/perioclinik.ca\/#website\"},\"datePublished\":\"2020-08-26T18:10:39+00:00\",\"dateModified\":\"2025-07-25T15:36:49+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/perioclinik.ca\/fr\/references\/#breadcrumb\"},\"inLanguage\":\"fr-FR\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/perioclinik.ca\/fr\/references\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/perioclinik.ca\/fr\/references\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/perioclinik.ca\/fr\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"R\u00e9f\u00e9rences\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/perioclinik.ca\/#website\",\"url\":\"https:\/\/perioclinik.ca\/\",\"name\":\"PerioClinik\",\"description\":\"Life Changing Dental Care\",\"publisher\":{\"@id\":\"https:\/\/perioclinik.ca\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/perioclinik.ca\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"fr-FR\"},{\"@type\":\"Organization\",\"@id\":\"https:\/\/perioclinik.ca\/#organization\",\"name\":\"PerioClinik\",\"url\":\"https:\/\/perioclinik.ca\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"fr-FR\",\"@id\":\"https:\/\/perioclinik.ca\/#\/schema\/logo\/image\/\",\"url\":\"https:\/\/perioclinik.ca\/wp-content\/uploads\/2018\/10\/PerioClinik-Logo_Color.png\",\"contentUrl\":\"https:\/\/perioclinik.ca\/wp-content\/uploads\/2018\/10\/PerioClinik-Logo_Color.png\",\"width\":164,\"height\":60,\"caption\":\"PerioClinik\"},\"image\":{\"@id\":\"https:\/\/perioclinik.ca\/#\/schema\/logo\/image\/\"},\"sameAs\":[\"https:\/\/www.facebook.com\/PerioClinikGatineau\/?locale=fr_FR\",\"https:\/\/www.instagram.com\/perioclinikgatineau\/?hl=fr\"]}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"R\u00e9f\u00e9rences | PerioClinik","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/perioclinik.ca\/fr\/references\/","og_locale":"fr_FR","og_type":"article","og_title":"R\u00e9f\u00e9rences | PerioClinik","og_description":"[vc_row full_width=\u00a0\u00bbstretch_row_content\u00a0\u00bb background_attachment=\u00a0\u00bbfixed\u00a0\u00bb lg_spacing=\u00a0\u00bbpadding_top:90;padding_bottom:90&Prime; background_image=\u00a0\u00bb4704&Prime; background_position=\u00a0\u00bbcenter\u00a0\u00bb el_class=\u00a0\u00bbref-form-parent\u00a0\u00bb][vc_column width=\u00a0\u00bb1\/4&Prime; sm_content_alignment=\u00a0\u00bbcenter\u00a0\u00bb offset=\u00a0\u00bbvc_col-lg-offset-6 vc_col-lg-6&Prime; lg_spacing=\u00a0\u00bbmargin_right:100&Prime; md_spacing=\u00a0\u00bbmargin_right:90&Prime; sm_spacing=\u00a0\u00bbmargin_right:0&Prime; xs_spacing=\u00a0\u00bbmargin_right:0&Prime; el_class=\u00a0\u00bbconsult\u00a0\u00bb][vc_row_inner background_color=\u00a0\u00bbcustom\u00a0\u00bb lg_spacing=\u00a0\u00bbmargin_right:0;margin_left:0;padding_top:50;padding_right:35;padding_bottom:50;padding_left:35&Prime; custom_background_color=\u00a0\u00bb#ffffff\u00a0\u00bb sm_spacing=\u00a0\u00bbpadding_top:30;padding_right:15;padding_bottom:30;padding_left:15&Prime;][vc_column_inner el_class=\u00a0\u00bbref-form\u00a0\u00bb offset=\u00a0\u00bbvc_col-md-12 vc_col-sm-offset-0 vc_col-xs-12&Prime;][tm_heading tag=\u00a0\u00bbh1&Prime; custom_google_font=\u00a0\u00bb\u00a0\u00bb google_fonts=\u00a0\u00bbfont_family:Poppins%3A300%2Cregular%2C500%2C600%2C700|font_style:300%20light%20regular%3A300%3Anormal\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbR\u00e9f\u00e9rence de patient\u00a0\u00bb font_size=\u00a0\u00bblg:36&Prime;][tm_spacer size=\u00a0\u00bblg:15&Prime;][tm_heading tag=\u00a0\u00bbdiv\u00a0\u00bb custom_google_font=\u00a0\u00bb\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb text=\u00a0\u00bbRemplissez le formulaire ci-dessous pour orienter un patient vers la PerioClinik. Nous avons h\u00e2te de discuter avec vous de votre patient.\u00a0\u00bb max_width=\u00a0\u00bb406px\u00a0\u00bb][tm_spacer size=\u00a0\u00bblg:40&Prime;][vc_column_text css=\u00a0\u00bb\u00a0\u00bb][\/vc_column_text][tm_spacer size=\u00a0\u00bblg:15&Prime;][vc_btn title=\u00a0\u00bbT\u00e9l\u00e9charger le formulaire de r\u00e9f\u00e9rence \u00e0 envoyer par t\u00e9l\u00e9copieur ou par courriel. Fax : 819-201-8615&Prime; style=\u00a0\u00bbflat\u00a0\u00bb shape=\u00a0\u00bbsquare\u00a0\u00bb color=\u00a0\u00bbblack\u00a0\u00bb align=\u00a0\u00bbcenter\u00a0\u00bb i_icon_fontawesome=\u00a0\u00bbfas fa-cloud-download-alt\u00a0\u00bb css=\u00a0\u00bb\u00a0\u00bb add_icon=\u00a0\u00bbtrue\u00a0\u00bb link=\u00a0\u00bburl:%2Fwp-content%2Fuploads%2F2018%2F10%2FFormulaire-de-reference-Perioclinik.pdf||target:%20_blank|\u00a0\u00bb][\/vc_column_inner][\/vc_row_inner][\/vc_column][vc_column width=\u00a0\u00bb3\/4&Prime;][\/vc_column][\/vc_row]","og_url":"https:\/\/perioclinik.ca\/fr\/references\/","og_site_name":"PerioClinik","article_publisher":"https:\/\/www.facebook.com\/PerioClinikGatineau\/?locale=fr_FR","article_modified_time":"2025-07-25T15:36:49+00:00","twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"1 minute"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/perioclinik.ca\/fr\/references\/","url":"https:\/\/perioclinik.ca\/fr\/references\/","name":"R\u00e9f\u00e9rences | PerioClinik","isPartOf":{"@id":"https:\/\/perioclinik.ca\/#website"},"datePublished":"2020-08-26T18:10:39+00:00","dateModified":"2025-07-25T15:36:49+00:00","breadcrumb":{"@id":"https:\/\/perioclinik.ca\/fr\/references\/#breadcrumb"},"inLanguage":"fr-FR","potentialAction":[{"@type":"ReadAction","target":["https:\/\/perioclinik.ca\/fr\/references\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/perioclinik.ca\/fr\/references\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/perioclinik.ca\/fr\/"},{"@type":"ListItem","position":2,"name":"R\u00e9f\u00e9rences"}]},{"@type":"WebSite","@id":"https:\/\/perioclinik.ca\/#website","url":"https:\/\/perioclinik.ca\/","name":"PerioClinik","description":"Life Changing Dental Care","publisher":{"@id":"https:\/\/perioclinik.ca\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/perioclinik.ca\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"fr-FR"},{"@type":"Organization","@id":"https:\/\/perioclinik.ca\/#organization","name":"PerioClinik","url":"https:\/\/perioclinik.ca\/","logo":{"@type":"ImageObject","inLanguage":"fr-FR","@id":"https:\/\/perioclinik.ca\/#\/schema\/logo\/image\/","url":"https:\/\/perioclinik.ca\/wp-content\/uploads\/2018\/10\/PerioClinik-Logo_Color.png","contentUrl":"https:\/\/perioclinik.ca\/wp-content\/uploads\/2018\/10\/PerioClinik-Logo_Color.png","width":164,"height":60,"caption":"PerioClinik"},"image":{"@id":"https:\/\/perioclinik.ca\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/PerioClinikGatineau\/?locale=fr_FR","https:\/\/www.instagram.com\/perioclinikgatineau\/?hl=fr"]}]}},"_links":{"self":[{"href":"https:\/\/perioclinik.ca\/fr\/wp-json\/wp\/v2\/pages\/4546","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/perioclinik.ca\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/perioclinik.ca\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/perioclinik.ca\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/perioclinik.ca\/fr\/wp-json\/wp\/v2\/comments?post=4546"}],"version-history":[{"count":0,"href":"https:\/\/perioclinik.ca\/fr\/wp-json\/wp\/v2\/pages\/4546\/revisions"}],"wp:attachment":[{"href":"https:\/\/perioclinik.ca\/fr\/wp-json\/wp\/v2\/media?parent=4546"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}