{"id":87,"date":"2024-12-19T11:43:20","date_gmt":"2024-12-19T10:43:20","guid":{"rendered":"https:\/\/ophtinblue.com\/?page_id=87"},"modified":"2024-12-19T15:15:29","modified_gmt":"2024-12-19T14:15:29","slug":"fiche-de-liaison","status":"publish","type":"page","link":"https:\/\/ophtinblue.com\/index.php\/fiche-de-liaison\/","title":{"rendered":"Fiche de liaison"},"content":{"rendered":"<div  class=\"tatsu-BJZYAdOWHkl tatsu-section  tatsu-bg-overlay   tatsu-clearfix\" data-title=\"\"  data-headerscheme=\"background--dark\"><div class='tatsu-section-pad clearfix' data-padding='{\"d\":\"90px 0px 90px 0px\"}' data-padding-top='90px'><div class=\"tatsu-row-wrap  tatsu-wrap tatsu-row-one-col tatsu-row-has-one-cols tatsu-medium-gutter tatsu-reg-cols  tatsu-clearfix tatsu-BJetAO_Wryx\" ><div  class=\"tatsu-row \" ><div  class=\"tatsu-column  tatsu-bg-overlay tatsu-one-col tatsu-column-image-none tatsu-column-effect-none  tatsu-BJYCudWrkg\"  data-parallax-speed=\"0\" style=\"\"><div class=\"tatsu-column-inner \" ><div class=\"tatsu-column-pad-wrap\"><div class=\"tatsu-column-pad\" ><div  class=\"special-heading-wrap style1 oshine-module  tatsu-SylkYdWB1x  \" ><div class=\"special-heading align-center\"><h3 class=\"special-h-tag\" >Fiche de Liaison<\/h3><div class=\"sub-title margin-bottom  special-subtitle\">\n<p><strong><span style=\"color: #245899;\">Opht in Blue<\/span><\/strong><\/p>\n<\/div><div class=\"sep-with-icon-wrap margin-bottom\"><span class=\"sep-with-icon\" ><\/span><i class=\"sep-icon font-icon tatsu-icon-eye2\"><\/i><span class=\"sep-with-icon\" ><\/span><\/div><\/div><style>.tatsu-SylkYdWB1x .special-h-tag{color: rgba(36,88,153,1) ;}.tatsu-SylkYdWB1x .sep-icon.oshine_diamond{background: rgba(36,88,153,1);}.tatsu-SylkYdWB1x .sep-icon{color: rgba(36,88,153,1) ;}.tatsu-SylkYdWB1x .sep-with-icon{height: 1px;width: 20px;background: #efefef;}<\/style><\/div><div  class=\"tatsu-shortcode-module tatsu-module tatsu-SkRfYdZSkx   \"  ><script>\nvar 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class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php\/wp-json\/wp\/v2\/pages\/87' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du v\u00e9t\u00e9rinaire traitant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            \n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>E-mail du v\u00e9t\u00e9rinaire traitant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_1_3' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_24'>Nom du propri\u00e9taire de l&#039;animal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_1_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>T\u00e9l\u00e9phone du propri\u00e9taire de l&#039;animal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Adresse du propri\u00e9taire de l&#039;animal<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Nom de l&#039;animal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>\u00c2ge de l&#039;animal<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_1_10' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Esp\u00e8ce de l&#039;animal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Chien'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Chien<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Chat'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>Chat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='gf_other_choice'  id='choice_1_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_11_2' id='label_1_11_2' class='gform-field-label gform-field-label--type-inline'>Autre<\/label><br \/><input id='input_1_11_other' class='gchoice_other_control' name='input_11_other' type='text' value='Autre' aria-label='Autre choix, veuillez sp\u00e9cifier'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Je souhaite une prise en charge en urgence<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_1_12'>(le cas sera pris en charge le plus rapidement possible. Cela n\u00e9cessitera un surco\u00fbt pour les propri\u00e9taires)<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_12'>\n\t\t\t<div class='gchoice gchoice_1_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Non'  id='choice_1_12_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_12\"   \/>\n\t\t\t\t\t<label for='choice_1_12_0' id='label_1_12_0' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Oui'  id='choice_1_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_12_1' id='label_1_12_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Niveau de prise en charge souhait\u00e9<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_13'>\n\t\t\t<div class='gchoice gchoice_1_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Consultation'  id='choice_1_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_0' id='label_1_13_0' class='gform-field-label gform-field-label--type-inline'>Consultation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Consultation et examens compl\u00e9mentaires'  id='choice_1_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_1' id='label_1_13_1' class='gform-field-label gform-field-label--type-inline'>Consultation et examens compl\u00e9mentaires<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Consultation, examens compl\u00e9mentaires et traitement m\u00e9dical et\/ou chirurgical'  id='choice_1_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_2' id='label_1_13_2' class='gform-field-label gform-field-label--type-inline'>Consultation, examens compl\u00e9mentaires et traitement m\u00e9dical et\/ou chirurgical<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Examens compl\u00e9mentaires seuls'  id='choice_1_13_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_3' id='label_1_13_3' class='gform-field-label gform-field-label--type-inline'>Examens compl\u00e9mentaires seuls<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_13_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Autre'  id='choice_1_13_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_13_4' id='label_1_13_4' class='gform-field-label gform-field-label--type-inline'>Autre<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_14\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_14'>Pr\u00e9cisez<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_14' id='input_1_14' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Comm\u00e9moratifs<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_15' id='input_1_15' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Examens compl\u00e9mentaires d\u00e9j\u00e0 r\u00e9alis\u00e9s<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_1_17' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Hypoth\u00e8ses diagnostiques<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_1_18' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>Traitement administr\u00e9s<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_19' id='input_1_19' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div 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data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_1_21&quot;,&quot;container&quot;:&quot;gform_multifile_upload_1_21&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_1_21&quot;,&quot;filelist&quot;:&quot;gform_preview_1_21&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/ophtinblue.com\\\/?gf_page=75c85baf973b105&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/ophtinblue.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/ophtinblue.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers 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