{"id":746,"date":"2024-04-10T19:12:17","date_gmt":"2024-04-10T19:12:17","guid":{"rendered":"https:\/\/espacedentairemd.com\/formulaire-consentement-adulte\/"},"modified":"2024-04-10T19:58:37","modified_gmt":"2024-04-10T19:58:37","slug":"consent-form-adult","status":"publish","type":"page","link":"https:\/\/espacedentairemd.com\/en\/consent-form-adult\/","title":{"rendered":"Consent form adult"},"content":{"rendered":"\n<style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-luu6ou9l-127a82dcdd6f9d9e52a31ba582d0fb8c\">\n.avia-section.av-luu6ou9l-127a82dcdd6f9d9e52a31ba582d0fb8c{\nbackground-color:#f1ede9;\nbackground-image:unset;\n}\n<\/style>\n<div id='av_section_1'  class='avia-section av-luu6ou9l-127a82dcdd6f9d9e52a31ba582d0fb8c main_color avia-section-default avia-no-border-styling  avia-builder-el-0  avia-builder-el-no-sibling  avia-bg-style-scroll container_wrap sidebar_right'  ><div class='container av-section-cont-open' ><main  role=\"main\" itemprop=\"mainContentOfPage\"  class='template-page content  av-content-small alpha units'><div class='post-entry post-entry-type-page post-entry-746'><div class='entry-content-wrapper clearfix'>\n<div  class='flex_column av-agk3z-9aa92626c7c4027bd96deac32dc3e8c1 av_one_full  avia-builder-el-1  avia-builder-el-no-sibling  first flex_column_div  '     ><style type=\"text\/css\" data-created_by=\"avia_inline_auto\" id=\"style-css-av-luu6st1q-69cc7789a8acfe7d18fc4937612f3ef3\">\n#top .av_textblock_section.av-luu6st1q-69cc7789a8acfe7d18fc4937612f3ef3 .avia_textblock{\ncolor:#000000;\n}\n<\/style>\n<section  class='av_textblock_section av-luu6st1q-69cc7789a8acfe7d18fc4937612f3ef3 '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock av_inherit_color'  itemprop=\"text\" ><h3>Consent form for the collection and use of personal information<\/h3>\n<\/div><\/section><br \/>\n<section  class='av_textblock_section av-luu6oku2-fe44bc9dbdd93334f945571d692242bf '   itemscope=\"itemscope\" itemtype=\"https:\/\/schema.org\/CreativeWork\" ><div class='avia_textblock'  itemprop=\"text\" ><p style=\"text-align: center;\"><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-742\"><form id=\"wpforms-form-742\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"742\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/746\" data-token=\"abb7561acc69d95d0af95858fede5e03\" data-token-time=\"1784240165\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-742-field_3-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"3\"><div id=\"wpforms-742-field_3\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-742-field_3-error\"><p>I,<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-742-field_4-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"4\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-742-field_4\" aria-hidden=\"false\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-742-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" placeholder=\"Name\" aria-errormessage=\"wpforms-742-field_4-error\" required><\/div><div id=\"wpforms-742-field_5-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"5\"><div id=\"wpforms-742-field_5\" class=\"wpforms-field-large wpforms-field-row\" aria-errormessage=\"wpforms-742-field_5-error\"><p class=\"p1\">hereby consent to the collection, use and disclosure of my personal information by&nbsp;ESPACE DENTAIRE MD&nbsp;for the purpose of providing me with dental services.<\/p>\n<p class=\"p1\">I acknowledge that I have received information about how my personal information will be collected, used, shared, stored and protected.<\/p>\n<p class=\"p1\">I acknowledge that I have received information about my rights with respect to my personal information.<\/p>\n<p class=\"p1\">The foregoing information is contained in the&nbsp;ESPACE DENTAIRE MD&nbsp;Privacy Policy.<\/p>\n<p class=\"p1\">I understand that consent is valid for as long as I am a patient of&nbsp;ESPACE DENTAIRE MD&nbsp;and that I may withdraw my consent to the collection and use of my personal information at any time in accordance with the procedure described in the&nbsp;ESPACE DENTAIRE MD&nbsp;Privacy Policy. However, this may prevent&nbsp;ESPACE DENTAIRE MD&nbsp;from providing me with dental services.<\/p>\n<p class=\"p1\">I have read and understood the above information and voluntarily consent to the collection and use of my personal information as described.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-742-field_7-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-742-field_7\">Signature <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-742-field_7\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][7]\" autocomplete=\"off\" aria-errormessage=\"wpforms-742-field_7-error\" required><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" 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wpforms-field-date-time\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-742-field_6\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-742-field_6\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][6][date]\" aria-errormessage=\"wpforms-742-field_6-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"742\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/pages\/746\"><button type=\"submit\" 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clearfix'>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"_links":{"self":[{"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/pages\/746"}],"collection":[{"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/comments?post=746"}],"version-history":[{"count":2,"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/pages\/746\/revisions"}],"predecessor-version":[{"id":782,"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/pages\/746\/revisions\/782"}],"wp:attachment":[{"href":"https:\/\/espacedentairemd.com\/en\/wp-json\/wp\/v2\/media?parent=746"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}