{"id":659978,"date":"2025-12-05T13:02:00","date_gmt":"2025-12-05T18:02:00","guid":{"rendered":"https:\/\/dev.cliniquedentairelaval.ca\/?page_id=659978"},"modified":"2025-12-08T12:28:03","modified_gmt":"2025-12-08T17:28:03","slug":"appointment","status":"publish","type":"page","link":"https:\/\/dev.cliniquedentairelaval.ca\/en\/appointment\/","title":{"rendered":"Appointment"},"content":{"rendered":"<form class=\"c-form\">\n\n        \t\t\t\n\t\t\n\t\t<h2 class=\"c-form_heading\">Form<\/h2>\n\n\t\t<input id=\"send_mode\" type=\"hidden\" value=\"\" >\n\t\t<input id=\"app_id\" type=\"hidden\" value=\"\" >\n\t\t<input id=\"api_key\" type=\"hidden\" value=\"\" >\n\t\t<input type=\"hidden\" name=\"form_recipients_email\" id=\"form_recipients_email\" value=\"sslatnia@ploggmedia.com\">\n\n\t\t\n\t\t<div class=\"c-form_row\">\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">\u00cates-vous d\u00e9j\u00e0 patient \u00e0 la clinique?<\/h3>\n\t\t\t\t\t\t<div class=\"c-radio-group o-layout -col -gutter-y-xs\">\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"yes\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"patient\" id=\"yes\" checked>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Oui<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"no\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"patient\" id=\"no\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Non<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">What&#8217;s the reason for the appointment?<\/h3>\n\t\t\t\t\t\t<div class=\"c-radio-group o-layout -col -gutter-y-xs\">\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"specific-consultation\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"reason\" id=\"specific-consultation\" checked>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Consultation sp\u00e9cifique\u00a0<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"examination-and-cleaning\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"reason\" id=\"examination-and-cleaning\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Examen et nettoyage<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"other\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"reason\" id=\"other\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Other<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"c-form_row\">\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Pour qui s\u2019adresse ce rendez-vous?<\/h3>\n\t\t\t\t\t\t<div class=\"c-radio-group o-layout -col -gutter-y-xs\">\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"kid\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"who\" id=\"kid\" checked>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Enfant (0-12 ans)<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"teen\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"who\" id=\"teen\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Teenager<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"adult\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"who\" id=\"adult\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Adult<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Do you have a doctor&#8217;s preference?<\/h3>\n\t\t\t\t\t\t<div class=\"c-select\">\n\t\t\t\t\t\t\t\t<select name=\"preference\">\n\t\t\t\t\t\t\t\t\t\t<option>Non, aucune<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option>Dr. Annick Lapointe<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option>Dr. David Jacques-Michaud<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<option>Dr. Koushiya Sellathurai<\/option>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"c-form_row\">\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Avez-vous \u00e9t\u00e9 r\u00e9f\u00e9r\u00e9 \u00e0 notre clinique?<\/h3>\n\t\t\t\t\t\t<div class=\"c-radio-group o-layout -col -gutter-y-xs\">\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"yes-referred-by\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"referred\" id=\"yes-referred-by\" checked>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Oui<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"not-referred-by\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"referred\" id=\"not-referred-by\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">Non<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Si oui, par qui?<\/h3>\n\t\t\t\t\t\t<input id=\"referred-by\" class=\"c-text-field\" type=\"text\" name=\"referred_by\" placeholder=\"Si oui, par qui?\">\n\t\t\t\t\t\t<div class=\"c-form-helper\"><\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"c-form_row\">\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Vos disponibilit\u00e9s<\/h3>\n\t\t\t\t\t\t<div class=\"o-layout -gutter-y-xs\">\n\n\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t<label class=\"c-checkbox\" for=\"date_1\">\n\t\t\t\t\t\t\t\t\t<input class=\"c-checkbox_input\" checked type=\"checkbox\" name=\"date\" id=\"date_1\" value=\"Monday\">\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_check\"><\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_label\">Monday<\/span>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t<label class=\"c-checkbox\" for=\"date_2\">\n\t\t\t\t\t\t\t\t\t<input class=\"c-checkbox_input\" type=\"checkbox\" name=\"date\" id=\"date_2\" value=\"Tuesday\">\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_check\"><\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_label\">Tuesday<\/span>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t<label class=\"c-checkbox\" for=\"date_3\">\n\t\t\t\t\t\t\t\t\t<input class=\"c-checkbox_input\" type=\"checkbox\" name=\"date\" id=\"date_3\" value=\"Wednesday\">\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_check\"><\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_label\">Wednesday<\/span>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t<label class=\"c-checkbox\" for=\"date_4\">\n\t\t\t\t\t\t\t\t\t<input class=\"c-checkbox_input\" type=\"checkbox\" name=\"date\" id=\"date_4\" value=\"Thursday\">\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_check\"><\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_label\">Thursday<\/span>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t<label class=\"c-checkbox\" for=\"date_5\">\n\t\t\t\t\t\t\t\t\t<input class=\"c-checkbox_input\" type=\"checkbox\" name=\"date\" id=\"date_5\" value=\"Friday\">\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_check\"><\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"c-checkbox_label\">Friday<\/span>\n\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Quel moment de la journ\u00e9e vous convient le mieux?<\/h3>\n\t\t\t\t\t\t<div class=\"c-radio-group o-layout -col -gutter-y-xs\">\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"am\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"when\" id=\"am\" checked>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">AM (8h30 \u00e0 12h00)<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"o-layout_item\">\n\t\t\t\t\t\t\t\t\t\t<label class=\"c-radio\" for=\"pm\">\n\t\t\t\t\t\t\t\t\t\t\t\t<input class=\"c-radio_input\" type=\"radio\" name=\"when\" id=\"pm\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_check\"><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"c-radio_label\">PM (12h00 \u00e0 17h00)<\/span>\n\t\t\t\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"c-form_row\">\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">First name<\/h3>\n\t\t\t\t\t\t<input class=\"c-text-field\" id=\"first_name\" name=\"first_name\" type=\"text\" placeholder=\"First name\">\n\t\t\t\t\t\t<div class=\"c-form-helper\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Last name<\/h3>\n\t\t\t\t\t\t<input class=\"c-text-field\" id=\"last_name\" name=\"last_name\" type=\"text\" placeholder=\"Last name\">\n\t\t\t\t\t\t<div class=\"c-form-helper\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Email address<\/h3>\n\t\t\t\t\t\t<input class=\"c-text-field\" id=\"email\" name=\"email\" type=\"email\" placeholder=\"Email address\">\n\t\t\t\t\t\t<div class=\"c-form-helper\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Phone<\/h3>\n\t\t\t\t\t\t<div class=\"intl-tel-input_ctn\">\n\t\t\t\t\t\t\t<input class=\"c-text-field appointment_intl_tel_input\" id=\"phone\" name=\"phone\" type=\"phone\" placeholder=\"Phone\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\n\t\t<div class=\"c-form_row\">\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<h3 class=\"c-heading -h4 c-form_label\">Message<\/h3>\n\t\t\t\t\t\t<textarea name=\"message\" id=\"message\" class=\"c-textarea\" placeholder=\"Message\" rows=\"6\"><\/textarea>\n\t\t\t\t\t\t<div class=\"c-form-helper\"><\/div>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\n\t\t<div class=\"c-form_submit u-text-center\">\n\t\t\t\t<div class=\"c-form_col\">\n\t\t\t\t\t\t<div class=\"c-form_recatcha g-recaptcha\" data-sitekey=\"6Ldi07oqAAAAAF0KfqO_kIkYmKwkZQwIzJEbbR7V\"><\/div>\n\t\t\t\t\t\t<input class=\"c-btn u-margin-bottom\" id=\"submit-form-1\" type=\"submit\" value=\"Envoyer\">\n\t\t\t\t\t\t<p class=\"c-typography -caption\">Ce site est prot\u00e9g\u00e9 par reCAPTCHA et les r\u00e8gles de confidentialit\u00e9 et les conditions d\u2019utilisation de Google s\u2019appliquent.<\/p>\n\t\t\t\t<\/div>\n\t\t<\/div>\n\n<\/form>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"\/templates\/appointment.php","meta":{"_acf_changed":false,"footnotes":""},"page-category":[],"class_list":["post-659978","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v25.1 (Yoast SEO v25.1) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Appointment - Clinique Dentaire Beaulieu, Lapointe et Associ\u00e9s \u00e0 Laval<\/title>\n<meta name=\"description\" content=\"Request an appointment now by completing the form for a specific consultation, a cleaning examination, or for a dental emergency.\" \/>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" 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