{"id":7817,"date":"2021-07-21T23:40:43","date_gmt":"2021-07-21T23:40:43","guid":{"rendered":"https:\/\/hyperbaricmontreal.com\/formulaire-de-consentement-du-patient\/"},"modified":"2023-04-18T14:27:50","modified_gmt":"2023-04-18T14:27:50","slug":"formulaire-de-consentement-du-patient","status":"publish","type":"page","link":"https:\/\/hyperbaricmontreal.com\/fr\/formulaire-de-consentement-du-patient\/","title":{"rendered":"FORMULAIRE DE CONSENTEMENT DU PATIENT"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-right:5%;--awb-padding-left:5%;--awb-margin-top:0px;--awb-background-color:rgba(229,229,229,0.4);--awb-box-shadow:5px 5px 21px 0px ;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-padding-top:1%;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-three\" style=\"--awb-font-size:45px;\"><h3 class=\"title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:45;line-height:2.2;\"><h2 style=\"text-align: center;\"><b>FORMULAIRE DE CONSENTEMENT DU PATIENT<\/b><\/h2><\/h3><\/div><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-3011 has-icon-alignment\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;--awb-form-placeholder-color:rgba(0,0,0,0.5);--awb-form-text-color:#000000;--awb-form-border-width-top:0px;--awb-form-border-width-bottom:2px;--awb-form-border-width-right:0px;--awb-form-border-width-left:0px;--awb-form-focus-border-color:#2474bb;--awb-form-focus-border-hover-color:rgba(36,116,187,0.5);--awb-icon-alignment-top:0px;--awb-icon-alignment-bottom:2px;--awb-icon-alignment-font-size:1em;\" data-form-id=\"3011\" data-config=\"{&quot;form_id&quot;:3011,&quot;form_post_id&quot;:3011,&quot;post_id&quot;:7817,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;first_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;Agreement&quot;:&quot; &quot;},&quot;field_logics&quot;:{&quot;first_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;notice_1&quot;:&quot;&quot;,&quot;Agreement&quot;:&quot;&quot;},&quot;field_types&quot;:{&quot;first_name&quot;:&quot;text&quot;,&quot;last_name&quot;:&quot;text&quot;,&quot;notice_1&quot;:&quot;notice&quot;,&quot;Agreement&quot;:&quot;checkbox&quot;,&quot;submit_1&quot;:&quot;submit&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;}\"><form action=\"https:\/\/hyperbaricmontreal.com\/fr\/formulaire-de-consentement-du-patient\/\" method=\"post\" class=\"fusion-form fusion-form-3011\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"3011\"><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"First name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" style=\"\" data-form-id=\"3011\"><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Last name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:20px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:10px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><p style=\"text-align: left;\"><span style=\"font-weight: 400;\">I authorize the performance of a procedure known as Hyperbaric Oxygen Therapy to be performed under the direction of Les Cours Medical Centre.<\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">As a patient, I give my consent to receive treatment of Hyperbaric Oxygen Therapy and have been informed of the benefits from Hyperbaric Oxygen Therapy and any possible side effects including and not limited to ear pain, sinus headache, transient problems with vision, difficulty with breathing or chest pain.<\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">I will advise Les Cours Hyperbaric Centre of any other treatments\u00a0 I am receiving from any other facility. I acknowledge that the nature of this procedure has been described to me in terms which I understand and all questions I have asked have been answered to my satisfaction.\u00a0<\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">Any complications or risks which may be associated with this procedure or possible alternatives have been explained. I am aware that Les Cours Hyperbaric Centre is using hyperbaric therapy for FDA approved as well as for investigational medical conditions and I acknowledge that no guarantees have been made to me concerning the results of examination or treatments from this therapy.<\/span><\/p>\n<p style=\"text-align: left;\"><span style=\"font-weight: 400;\">I hereby agree to hold harmless Les Cours Hyperbaric Centre and any of its employees from all cost, injury and damage incurred, any of which is caused by an activity, condition or event arising out of the performance, preparation for performance or nonperformance of treatment in this facility.<\/span><\/p>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"form-submission-notices data-notice_1\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success fusion-alert-capitalize alert-dismissable\" style=\"--awb-margin-top:20px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your message. It has been sent.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error fusion-alert-capitalize alert-dismissable\" style=\"--awb-margin-top:20px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"awb-icon-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. Please try again later.<\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div><\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" style=\"\" data-form-id=\"3011\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-agreement-1-0\" type=\"checkbox\" value=\"I have read and agree to abide by this checklist for the safety of myself and the clinic.\" name=\"Agreement[]\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"checkbox-agreement-1-0\">I have read and agree to abide by this checklist for the safety of myself and the clinic.<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"3011\"><div ><button type=\"submit\" class=\"fusion-button button-flat button-xlarge button-custom fusion-button-default button-1 fusion-button-span-yes  form-form-submit button-default\" style=\"--button_accent_color:#ffffff;--button_accent_hover_color:#ffffff;--button_border_hover_color:#ffffff;--button_gradient_top_color:#2474bb;--button_gradient_bottom_color:#2474bb;--button_gradient_top_color_hover:#2474bb;--button_gradient_bottom_color_hover:#2474bb;\" data-form-number=\"3011\" tabindex=\"\"><span class=\"fusion-button-text\">Submit<\/span><\/button><\/div><\/div><\/div><\/div><\/div><\/div><input type=\"hidden\" name=\"fusion_privacy_store_ip_ua\" value=\"false\"><input type=\"hidden\" name=\"fusion_privacy_expiration_interval\" value=\"48\"><input type=\"hidden\" name=\"privacy_expiration_action\" 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