{"id":1289,"date":"2020-06-24T13:41:06","date_gmt":"2020-06-24T11:41:06","guid":{"rendered":"http:\/\/www.angelsfriend.com\/?page_id=1289"},"modified":"2023-03-02T07:10:29","modified_gmt":"2023-03-02T06:10:29","slug":"single-parent-surrogacy-form","status":"publish","type":"page","link":"http:\/\/www.angelsfriend.com\/fr\/single-parent-surrogacy-form\/","title":{"rendered":"Single parent surrogacy form"},"content":{"rendered":"<div class=\"wp-blockade\"><!--themify_builder_content-->\n<div id=\"themify_builder_content-1289\" data-postid=\"1289\" class=\"themify_builder_content themify_builder_content-1289 themify_builder tf_clear\">\n                    <div  data-lazy=\"1\" class=\"module_row themify_builder_row tb_lcdd388 tb_first tf_w\">\n                        <div class=\"row_inner col_align_top tb_col_count_1 tf_box tf_rel\">\n                        <div  data-lazy=\"1\" class=\"module_column tb-column col-full tb_krg9389 first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_0q0034\" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-left ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" action=\"\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">FORMULAIRE POUR LA GPA<\/legend><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"13\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type='hidden' name='__fluent_form_embded_post_id' value='1289' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"2845fddd48\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/1289\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_1\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1 style=\"text-align: left\">VOS DETAILS<\/h1><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_5' aria-label=\"Service d\u00e9sir\u00e9\">Service d\u00e9sir\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_5\" id=\"ff_3_dropdown_5\" class=\"ff-el-form-control\" data-name=\"dropdown_5\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Surrogacy with own egg\"  >GPA sans don<\/option><option value=\"Surrogacy with egg donor\"  >GPA avec don<\/option><option value=\"Surrogacy with frozen egg\"  >GPA avec TEC<\/option><option value=\"Surrogacy with sperm donor\"  >GPA avec don de sperm<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_1' aria-label=\"Statut matrimonial\">Statut matrimonial<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_3_dropdown_1\" class=\"ff-el-form-control\" data-name=\"dropdown_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Single\"  >C\u00e9libataire<\/option><option value=\"Unmarried couple\"  >Couple pas mari\u00e9<\/option><option value=\"Married\"  >Couple mari\u00e9<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown' aria-label=\"Titre\">Titre<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_3_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Mrs\"  >Mme<\/option><option value=\"Mr\"  >Mr.<\/option><\/select><\/div><\/div><div data-type=\"name-element\" data-name=\"names\" class=\"ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' >Pr\u00e9nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_last_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_names_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime' aria-label=\"Date de naissance\">Date de naissance<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d-M-y' type=\"text\" name=\"datetime\" id=\"ff_3_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric-field_6' aria-label=\"T\u00e9l\u00e9phone\">T\u00e9l\u00e9phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_6\" id=\"ff_3_numeric-field_6\" class=\"ff-el-form-control\" data-name=\"numeric-field_6\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=\"Adresse\">Adresse<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_1_address_line_1_' aria-label=\"Appartement ou num\u00e9ro\">Appartement ou num\u00e9ro<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_3_address_1_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_1_address_line_2_' aria-label=\"Nom de la Rue\">Nom de la Rue<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_2]\" id=\"ff_3_address_1_address_line_2_\" class=\"ff-el-form-control\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_1_city_' aria-label=\"Ville\">Ville<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_3_address_1_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_1_zip_' aria-label=\"Code postal\">Code postal<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_3_address_1_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_address_1_country_' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_3_address_1_country_\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-key_name=\"country\" aria-invalid='false' aria-required=\"true\"><option value=''>S\u00e9lectionnez le pays<\/option><option value='AF' >Afghanistan<\/option><option value='ZA' >Afrique du Sud<\/option><option value='AL' >Albanie<\/option><option value='DZ' >Alg\u00e9rie<\/option><option value='DE' >Allemagne<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorre<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctique<\/option><option value='AG' >Antigua-et-Barbuda<\/option><option value='SA' >Arabie Saoudite<\/option><option value='AR' >Argentine<\/option><option value='AM' >Arm\u00e9nie<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australie<\/option><option value='AT' >Autriche<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbades<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgique<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermudes<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bi\u00e9lorussie<\/option><option value='BO' >Bolivie<\/option><option value='BA' >Bosnie-Herz\u00e9govine<\/option><option value='BW' >Botswana<\/option><option value='BN' >Brunei<\/option><option value='BR' >Br\u00e9sil<\/option><option value='BG' >Bulgarie<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodge<\/option><option value='CM' >Cameroun<\/option><option value='CA' >Canada<\/option><option value='CV' >Cap Vert<\/option><option value='CL' >Chili<\/option><option value='CN' >Chine<\/option><option value='CX' >Christmas Island<\/option><option value='CY' >Chypre<\/option><option value='CO' >Colombie<\/option><option value='KM' >Comores<\/option><option value='KP' >Cor\u00e9e du Nord<\/option><option value='KR' >Cor\u00e9e du Sud<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatie<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CI' >C\u00f4te-d\u2019Ivoire<\/option><option value='DK' >Danemark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominique<\/option><option value='ER' >Erythr\u00e9e<\/option><option value='ES' >Espagne<\/option><option value='EE' >Estonie<\/option><option value='US' >Etats-Unis (USA)<\/option><option value='FJ' >Fidji<\/option><option value='FI' >Finlande<\/option><option value='FR' >France<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambie<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GD' >Grenade<\/option><option value='GL' >Groenland<\/option><option value='GR' >Gr\u00e8ce<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernesey<\/option><option value='GN' >Guin\u00e9e<\/option><option value='GQ' >Guin\u00e9e \u00e9quatoriale<\/option><option value='GW' >Guin\u00e9e-Bissau<\/option><option value='GY' >Guyane<\/option><option value='GF' >Guyane Fran\u00e7aise<\/option><option value='GE' >G\u00e9orgie<\/option><option value='GS' >G\u00e9orgie du Sud \/ \u00eeles Sandwich<\/option><option value='HT' >Ha\u00efti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hongrie<\/option><option value='IN' >Inde<\/option><option value='ID' >Indon\u00e9sie<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlande<\/option><option value='IS' >Islande<\/option><option value='IL' >Isra\u00ebl<\/option><option value='IT' >Italie<\/option><option value='JM' >Jama\u00efque<\/option><option value='JP' >Japon<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordanie<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kowe\u00eft<\/option><option value='KG' >Kyrgyzstan<\/option><option value='RE' >La R\u00e9union<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonie<\/option><option value='LB' >Liban<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libye<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituanie<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., Chine<\/option><option value='MK' >Mac\u00e9doine<\/option><option value='MG' >Madagascar<\/option><option value='MY' >Malaisie<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malte<\/option><option value='MA' >Maroc<\/option><option value='MQ' >Martinique<\/option><option value='MU' >Maurice<\/option><option value='MR' >Mauritanie<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexique<\/option><option value='FM' >Micron\u00e9sie<\/option><option value='MD' >Moldavie<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolie<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibie<\/option><option value='NR' >Nauru<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norv\u00e8ge<\/option><option value='NC' >Nouvelle-Cal\u00e9donie<\/option><option value='NZ' >Nouvelle-Z\u00e9lande<\/option><option value='NP' >N\u00e9pal<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PA' >Panama<\/option><option value='PG' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='PY' >Paraguay<\/option><option value='NL' >Pays-Bas<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Pologne<\/option><option value='PF' >Polyn\u00e9sie Fran\u00e7aise<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='PE' >P\u00e9rou<\/option><option value='QA' >Qatar<\/option><option value='RO' >Roumanie<\/option><option value='GB' >Royaume-Uni (UK)<\/option><option value='RU' >Russie<\/option><option value='RW' >Rwanda<\/option><option value='CF' >R\u00e9publique Centrafricaine<\/option><option value='DO' >R\u00e9publique Dominicaine<\/option><option value='CZ' >R\u00e9publique Tch\u00e8que<\/option><option value='CG' >R\u00e9publique du Congo (Brazzaville)<\/option><option value='CD' >R\u00e9publique d\u00e9mocratique du Congo (Kinshasa)<\/option><option value='BQ' >Saba, Saint-Eustache et Bonaire<\/option><option value='EH' >Sahara occidental<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='PM' >Saint Pierre et Miquelon<\/option><option value='KN' >Saint-Kitts-et-Nevis<\/option><option value='MF' >Saint-Martin (partie fran\u00e7aise)<\/option><option value='SX' >Saint-Martin (partie n\u00e9erlandaise)<\/option><option value='VC' >Saint-Vincent-et-les-Grenadines<\/option><option value='SH' >Sainte-H\u00e9l\u00e8ne<\/option><option value='LC' >Sainte-Lucie<\/option><option value='SV' >Salvador<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tom\u00e9-et-Principe<\/option><option value='RS' >Serbie<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapour<\/option><option value='SK' >Slovaquie<\/option><option value='SI' >Slov\u00e9nie<\/option><option value='SO' >Somalie<\/option><option value='SD' >Soudan<\/option><option value='SS' >Soudan du Sud<\/option><option value='LK' >Sri Lanka<\/option><option value='CH' >Suisse<\/option><option value='SR' >Suriname<\/option><option value='SE' >Su\u00e8de<\/option><option value='SJ' >Svalbard et Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SY' >Syrie<\/option><option value='SN' >S\u00e9n\u00e9gal<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzanie<\/option><option value='TD' >Tchad<\/option><option value='TF' >Terres Australes Fran\u00e7aises<\/option><option value='PS' >Territoire Palestinien<\/option><option value='IO' >Territoire britannique de l&rsquo;oc\u00e9an Indien<\/option><option value='TH' >Thailande<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinit\u00e9-et-Tobago<\/option><option value='TN' >Tunisie<\/option><option value='TM' >Turkm\u00e9nistan<\/option><option value='TR' >Turquie<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis et Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambie<\/option><option value='ZW' >Zimbabwe<\/option><option value='EG' >\u00c9gypte<\/option><option value='AE' >\u00c9mirats Arabes Unis<\/option><option value='EC' >\u00c9quateur<\/option><option value='ET' >\u00c9thiopie<\/option><option value='BV' >\u00cele Bouvet<\/option><option value='NF' >\u00cele Norfolk<\/option><option value='IM' >\u00cele de Man<\/option><option value='AX' >\u00celes Aland<\/option><option value='KY' >\u00celes Ca\u00efmans<\/option><option value='CC' >\u00celes Cocos<\/option><option value='CK' >\u00celes Cook<\/option><option value='FK' >\u00celes Falkland<\/option><option value='FO' >\u00celes F\u00e9ro\u00e9<\/option><option value='HM' >\u00celes Heard-et-MacDonald<\/option><option value='MH' >\u00celes Marshall<\/option><option value='UM' >\u00celes Mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='SB' >\u00celes Salomon<\/option><option value='TC' >\u00celes Turques et Ca\u00efques<\/option><option value='VI' >\u00celes Vierges am\u00e9ricaines (US)<\/option><option value='VG' >\u00celes Vierges britanniques<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_country-list_1' aria-label=\"Nationalit\u00e9\">Nationalit\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list_1\" id=\"ff_3_country-list_1\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-name=\"country-list_1\" aria-invalid='false' aria-required=\"true\"><option value=''>S\u00e9lectionnez le pays<\/option><option value='AF' >Afghanistan<\/option><option value='ZA' >Afrique du Sud<\/option><option value='AL' >Albanie<\/option><option value='DZ' >Alg\u00e9rie<\/option><option value='DE' >Allemagne<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorre<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctique<\/option><option value='AG' >Antigua-et-Barbuda<\/option><option value='SA' >Arabie Saoudite<\/option><option value='AR' >Argentine<\/option><option value='AM' >Arm\u00e9nie<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australie<\/option><option value='AT' >Autriche<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbades<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgique<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermudes<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bi\u00e9lorussie<\/option><option value='BO' >Bolivie<\/option><option value='BA' >Bosnie-Herz\u00e9govine<\/option><option value='BW' >Botswana<\/option><option value='BN' >Brunei<\/option><option value='BR' >Br\u00e9sil<\/option><option value='BG' >Bulgarie<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodge<\/option><option value='CM' >Cameroun<\/option><option value='CA' >Canada<\/option><option value='CV' >Cap Vert<\/option><option value='CL' >Chili<\/option><option value='CN' >Chine<\/option><option value='CX' >Christmas Island<\/option><option value='CY' >Chypre<\/option><option value='CO' >Colombie<\/option><option value='KM' >Comores<\/option><option value='KP' >Cor\u00e9e du Nord<\/option><option value='KR' >Cor\u00e9e du Sud<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatie<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CI' >C\u00f4te-d\u2019Ivoire<\/option><option value='DK' >Danemark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominique<\/option><option value='ER' >Erythr\u00e9e<\/option><option value='ES' >Espagne<\/option><option value='EE' >Estonie<\/option><option value='US' >Etats-Unis (USA)<\/option><option value='FJ' >Fidji<\/option><option value='FI' >Finlande<\/option><option value='FR' >France<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambie<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GD' >Grenade<\/option><option value='GL' >Groenland<\/option><option value='GR' >Gr\u00e8ce<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernesey<\/option><option value='GN' >Guin\u00e9e<\/option><option value='GQ' >Guin\u00e9e \u00e9quatoriale<\/option><option value='GW' >Guin\u00e9e-Bissau<\/option><option value='GY' >Guyane<\/option><option value='GF' >Guyane Fran\u00e7aise<\/option><option value='GE' >G\u00e9orgie<\/option><option value='GS' >G\u00e9orgie du Sud \/ \u00eeles Sandwich<\/option><option value='HT' >Ha\u00efti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hongrie<\/option><option value='IN' >Inde<\/option><option value='ID' >Indon\u00e9sie<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlande<\/option><option value='IS' >Islande<\/option><option value='IL' >Isra\u00ebl<\/option><option value='IT' >Italie<\/option><option value='JM' >Jama\u00efque<\/option><option value='JP' >Japon<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordanie<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kowe\u00eft<\/option><option value='KG' >Kyrgyzstan<\/option><option value='RE' >La R\u00e9union<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonie<\/option><option value='LB' >Liban<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libye<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituanie<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., Chine<\/option><option value='MK' >Mac\u00e9doine<\/option><option value='MG' >Madagascar<\/option><option value='MY' >Malaisie<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malte<\/option><option value='MA' >Maroc<\/option><option value='MQ' >Martinique<\/option><option value='MU' >Maurice<\/option><option value='MR' >Mauritanie<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexique<\/option><option value='FM' >Micron\u00e9sie<\/option><option value='MD' >Moldavie<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolie<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibie<\/option><option value='NR' >Nauru<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norv\u00e8ge<\/option><option value='NC' >Nouvelle-Cal\u00e9donie<\/option><option value='NZ' >Nouvelle-Z\u00e9lande<\/option><option value='NP' >N\u00e9pal<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PA' >Panama<\/option><option value='PG' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='PY' >Paraguay<\/option><option value='NL' >Pays-Bas<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Pologne<\/option><option value='PF' >Polyn\u00e9sie Fran\u00e7aise<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='PE' >P\u00e9rou<\/option><option value='QA' >Qatar<\/option><option value='RO' >Roumanie<\/option><option value='GB' >Royaume-Uni (UK)<\/option><option value='RU' >Russie<\/option><option value='RW' >Rwanda<\/option><option value='CF' >R\u00e9publique Centrafricaine<\/option><option value='DO' >R\u00e9publique Dominicaine<\/option><option value='CZ' >R\u00e9publique Tch\u00e8que<\/option><option value='CG' >R\u00e9publique du Congo (Brazzaville)<\/option><option value='CD' >R\u00e9publique d\u00e9mocratique du Congo (Kinshasa)<\/option><option value='BQ' >Saba, Saint-Eustache et Bonaire<\/option><option value='EH' >Sahara occidental<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='PM' >Saint Pierre et Miquelon<\/option><option value='KN' >Saint-Kitts-et-Nevis<\/option><option value='MF' >Saint-Martin (partie fran\u00e7aise)<\/option><option value='SX' >Saint-Martin (partie n\u00e9erlandaise)<\/option><option value='VC' >Saint-Vincent-et-les-Grenadines<\/option><option value='SH' >Sainte-H\u00e9l\u00e8ne<\/option><option value='LC' >Sainte-Lucie<\/option><option value='SV' >Salvador<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tom\u00e9-et-Principe<\/option><option value='RS' >Serbie<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapour<\/option><option value='SK' >Slovaquie<\/option><option value='SI' >Slov\u00e9nie<\/option><option value='SO' >Somalie<\/option><option value='SD' >Soudan<\/option><option value='SS' >Soudan du Sud<\/option><option value='LK' >Sri Lanka<\/option><option value='CH' >Suisse<\/option><option value='SR' >Suriname<\/option><option value='SE' >Su\u00e8de<\/option><option value='SJ' >Svalbard et Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SY' >Syrie<\/option><option value='SN' >S\u00e9n\u00e9gal<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzanie<\/option><option value='TD' >Tchad<\/option><option value='TF' >Terres Australes Fran\u00e7aises<\/option><option value='PS' >Territoire Palestinien<\/option><option value='IO' >Territoire britannique de l&rsquo;oc\u00e9an Indien<\/option><option value='TH' >Thailande<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinit\u00e9-et-Tobago<\/option><option value='TN' >Tunisie<\/option><option value='TM' >Turkm\u00e9nistan<\/option><option value='TR' >Turquie<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis et Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambie<\/option><option value='ZW' >Zimbabwe<\/option><option value='EG' >\u00c9gypte<\/option><option value='AE' >\u00c9mirats Arabes Unis<\/option><option value='EC' >\u00c9quateur<\/option><option value='ET' >\u00c9thiopie<\/option><option value='BV' >\u00cele Bouvet<\/option><option value='NF' >\u00cele Norfolk<\/option><option value='IM' >\u00cele de Man<\/option><option value='AX' >\u00celes Aland<\/option><option value='KY' >\u00celes Ca\u00efmans<\/option><option value='CC' >\u00celes Cocos<\/option><option value='CK' >\u00celes Cook<\/option><option value='FK' >\u00celes Falkland<\/option><option value='FO' >\u00celes F\u00e9ro\u00e9<\/option><option value='HM' >\u00celes Heard-et-MacDonald<\/option><option value='MH' >\u00celes Marshall<\/option><option value='UM' >\u00celes Mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='SB' >\u00celes Salomon<\/option><option value='TC' >\u00celes Turques et Ca\u00efques<\/option><option value='VI' >\u00celes Vierges am\u00e9ricaines (US)<\/option><option value='VG' >\u00celes Vierges britanniques<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_1' aria-label=\"Groupe sanguin et Rh\u00e9sus\">Groupe sanguin et Rh\u00e9sus<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric-field_5' aria-label=\"Taille (cm)\">Taille (cm)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_5\" id=\"ff_3_numeric-field_5\" class=\"ff-el-form-control\" data-name=\"numeric-field_5\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric-field_3' aria-label=\"Poids (kg)\">Poids (kg)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_3\" id=\"ff_3_numeric-field_3\" class=\"ff-el-form-control\" data-name=\"numeric-field_3\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_2' aria-label=\"Occupation\">Occupation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_3_input_text_2\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_4' aria-label=\"Education le plus \u00e9lev\u00e9\">Education le plus \u00e9lev\u00e9<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_3_input_text_4\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class=\"ff-el-group  has-conditions ff-el-section-break  ff_left\" data-name=\"section_break-3_2\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1>DETAILS DE VOTRE PARTENAIRE<\/h1><\/div><hr \/><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_2' aria-label=\"Titre\">Titre<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_3_dropdown_2\" class=\"ff-el-form-control\" data-name=\"dropdown_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Mr\"  >Mr.<\/option><option value=\"Mrs\"  >Mme<\/option><\/select><\/div><\/div><div data-type=\"name-element\" data-name=\"names_1\" class=\"has-conditions  ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_1_first_name_' >Pr\u00e9nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_3_names_1_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_1_last_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[last_name]\" id=\"ff_3_names_1_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime_1' aria-label=\"Date de naissance\">Date de naissance<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d-M-y' type=\"text\" name=\"datetime_1\" id=\"ff_3_datetime_1\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_1\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric-field' aria-label=\"T\u00e9l\u00e9phone\">T\u00e9l\u00e9phone<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field\" id=\"ff_3_numeric-field\" class=\"ff-el-form-control\" data-name=\"numeric-field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address has-conditions\" data-type=\"address-element\" data-name=\"address_4\" ><div class='ff-el-input--label'><label aria-label=\"Adresse (si different plus haut)\">Adresse (si different plus haut)<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_4_address_line_1_' aria-label=\"Num\u00e9ro de l&#039;appartement ou maison\">Num\u00e9ro de l'appartement ou maison<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_4[address_line_1]\" id=\"ff_3_address_4_address_line_1_\" class=\"ff-el-form-control\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_4_address_line_2_' aria-label=\"Nom de la Rue\">Nom de la Rue<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_4[address_line_2]\" id=\"ff_3_address_4_address_line_2_\" class=\"ff-el-form-control\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_4_city_' aria-label=\"Ville\">Ville<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_4[city]\" id=\"ff_3_address_4_city_\" class=\"ff-el-form-control\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_4_zip_' aria-label=\"Code postal\">Code postal<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_4[zip]\" id=\"ff_3_address_4_zip_\" class=\"ff-el-form-control\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_address_4_country_' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"address_4[country]\" id=\"ff_3_address_4_country_\" class=\"ff-el-form-control\" data-key_name=\"country\" aria-invalid='false' aria-required=\"false\"><option value=''><\/option><option value='AF' >Afghanistan<\/option><option value='ZA' >Afrique du Sud<\/option><option value='AL' >Albanie<\/option><option value='DZ' >Alg\u00e9rie<\/option><option value='DE' >Allemagne<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorre<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctique<\/option><option value='AG' >Antigua-et-Barbuda<\/option><option value='SA' >Arabie Saoudite<\/option><option value='AR' >Argentine<\/option><option value='AM' >Arm\u00e9nie<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australie<\/option><option value='AT' >Autriche<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbades<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgique<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermudes<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bi\u00e9lorussie<\/option><option value='BO' >Bolivie<\/option><option value='BA' >Bosnie-Herz\u00e9govine<\/option><option value='BW' >Botswana<\/option><option value='BN' >Brunei<\/option><option value='BR' >Br\u00e9sil<\/option><option value='BG' >Bulgarie<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodge<\/option><option value='CM' >Cameroun<\/option><option value='CA' >Canada<\/option><option value='CV' >Cap Vert<\/option><option value='CL' >Chili<\/option><option value='CN' >Chine<\/option><option value='CX' >Christmas Island<\/option><option value='CY' >Chypre<\/option><option value='CO' >Colombie<\/option><option value='KM' >Comores<\/option><option value='KP' >Cor\u00e9e du Nord<\/option><option value='KR' >Cor\u00e9e du Sud<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatie<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CI' >C\u00f4te-d\u2019Ivoire<\/option><option value='DK' >Danemark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominique<\/option><option value='ER' >Erythr\u00e9e<\/option><option value='ES' >Espagne<\/option><option value='EE' >Estonie<\/option><option value='US' >Etats-Unis (USA)<\/option><option value='FJ' >Fidji<\/option><option value='FI' >Finlande<\/option><option value='FR' >France<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambie<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GD' >Grenade<\/option><option value='GL' >Groenland<\/option><option value='GR' >Gr\u00e8ce<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernesey<\/option><option value='GN' >Guin\u00e9e<\/option><option value='GQ' >Guin\u00e9e \u00e9quatoriale<\/option><option value='GW' >Guin\u00e9e-Bissau<\/option><option value='GY' >Guyane<\/option><option value='GF' >Guyane Fran\u00e7aise<\/option><option value='GE' >G\u00e9orgie<\/option><option value='GS' >G\u00e9orgie du Sud \/ \u00eeles Sandwich<\/option><option value='HT' >Ha\u00efti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hongrie<\/option><option value='IN' >Inde<\/option><option value='ID' >Indon\u00e9sie<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlande<\/option><option value='IS' >Islande<\/option><option value='IL' >Isra\u00ebl<\/option><option value='IT' >Italie<\/option><option value='JM' >Jama\u00efque<\/option><option value='JP' >Japon<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordanie<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kowe\u00eft<\/option><option value='KG' >Kyrgyzstan<\/option><option value='RE' >La R\u00e9union<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonie<\/option><option value='LB' >Liban<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libye<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituanie<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., Chine<\/option><option value='MK' >Mac\u00e9doine<\/option><option value='MG' >Madagascar<\/option><option value='MY' >Malaisie<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malte<\/option><option value='MA' >Maroc<\/option><option value='MQ' >Martinique<\/option><option value='MU' >Maurice<\/option><option value='MR' >Mauritanie<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexique<\/option><option value='FM' >Micron\u00e9sie<\/option><option value='MD' >Moldavie<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolie<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibie<\/option><option value='NR' >Nauru<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norv\u00e8ge<\/option><option value='NC' >Nouvelle-Cal\u00e9donie<\/option><option value='NZ' >Nouvelle-Z\u00e9lande<\/option><option value='NP' >N\u00e9pal<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PA' >Panama<\/option><option value='PG' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='PY' >Paraguay<\/option><option value='NL' >Pays-Bas<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Pologne<\/option><option value='PF' >Polyn\u00e9sie Fran\u00e7aise<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='PE' >P\u00e9rou<\/option><option value='QA' >Qatar<\/option><option value='RO' >Roumanie<\/option><option value='GB' >Royaume-Uni (UK)<\/option><option value='RU' >Russie<\/option><option value='RW' >Rwanda<\/option><option value='CF' >R\u00e9publique Centrafricaine<\/option><option value='DO' >R\u00e9publique Dominicaine<\/option><option value='CZ' >R\u00e9publique Tch\u00e8que<\/option><option value='CG' >R\u00e9publique du Congo (Brazzaville)<\/option><option value='CD' >R\u00e9publique d\u00e9mocratique du Congo (Kinshasa)<\/option><option value='BQ' >Saba, Saint-Eustache et Bonaire<\/option><option value='EH' >Sahara occidental<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='PM' >Saint Pierre et Miquelon<\/option><option value='KN' >Saint-Kitts-et-Nevis<\/option><option value='MF' >Saint-Martin (partie fran\u00e7aise)<\/option><option value='SX' >Saint-Martin (partie n\u00e9erlandaise)<\/option><option value='VC' >Saint-Vincent-et-les-Grenadines<\/option><option value='SH' >Sainte-H\u00e9l\u00e8ne<\/option><option value='LC' >Sainte-Lucie<\/option><option value='SV' >Salvador<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tom\u00e9-et-Principe<\/option><option value='RS' >Serbie<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapour<\/option><option value='SK' >Slovaquie<\/option><option value='SI' >Slov\u00e9nie<\/option><option value='SO' >Somalie<\/option><option value='SD' >Soudan<\/option><option value='SS' >Soudan du Sud<\/option><option value='LK' >Sri Lanka<\/option><option value='CH' >Suisse<\/option><option value='SR' >Suriname<\/option><option value='SE' >Su\u00e8de<\/option><option value='SJ' >Svalbard et Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SY' >Syrie<\/option><option value='SN' >S\u00e9n\u00e9gal<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzanie<\/option><option value='TD' >Tchad<\/option><option value='TF' >Terres Australes Fran\u00e7aises<\/option><option value='PS' >Territoire Palestinien<\/option><option value='IO' >Territoire britannique de l&rsquo;oc\u00e9an Indien<\/option><option value='TH' >Thailande<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinit\u00e9-et-Tobago<\/option><option value='TN' >Tunisie<\/option><option value='TM' >Turkm\u00e9nistan<\/option><option value='TR' >Turquie<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis et Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambie<\/option><option value='ZW' >Zimbabwe<\/option><option value='EG' >\u00c9gypte<\/option><option value='AE' >\u00c9mirats Arabes Unis<\/option><option value='EC' >\u00c9quateur<\/option><option value='ET' >\u00c9thiopie<\/option><option value='BV' >\u00cele Bouvet<\/option><option value='NF' >\u00cele Norfolk<\/option><option value='IM' >\u00cele de Man<\/option><option value='AX' >\u00celes Aland<\/option><option value='KY' >\u00celes Ca\u00efmans<\/option><option value='CC' >\u00celes Cocos<\/option><option value='CK' >\u00celes Cook<\/option><option value='FK' >\u00celes Falkland<\/option><option value='FO' >\u00celes F\u00e9ro\u00e9<\/option><option value='HM' >\u00celes Heard-et-MacDonald<\/option><option value='MH' >\u00celes Marshall<\/option><option value='UM' >\u00celes Mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='SB' >\u00celes Salomon<\/option><option value='TC' >\u00celes Turques et Ca\u00efques<\/option><option value='VI' >\u00celes Vierges am\u00e9ricaines (US)<\/option><option value='VG' >\u00celes Vierges britanniques<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_country-list' aria-label=\"Nationalit\u00e9\">Nationalit\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_3_country-list\" class=\"ff-el-form-control\" data-name=\"country-list\" aria-invalid='false' aria-required=\"true\"><option value=''><\/option><option value='AF' >Afghanistan<\/option><option value='ZA' >Afrique du Sud<\/option><option value='AL' >Albanie<\/option><option value='DZ' >Alg\u00e9rie<\/option><option value='DE' >Allemagne<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorre<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctique<\/option><option value='AG' >Antigua-et-Barbuda<\/option><option value='SA' >Arabie Saoudite<\/option><option value='AR' >Argentine<\/option><option value='AM' >Arm\u00e9nie<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australie<\/option><option value='AT' >Autriche<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbades<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgique<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermudes<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bi\u00e9lorussie<\/option><option value='BO' >Bolivie<\/option><option value='BA' >Bosnie-Herz\u00e9govine<\/option><option value='BW' >Botswana<\/option><option value='BN' >Brunei<\/option><option value='BR' >Br\u00e9sil<\/option><option value='BG' >Bulgarie<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodge<\/option><option value='CM' >Cameroun<\/option><option value='CA' >Canada<\/option><option value='CV' >Cap Vert<\/option><option value='CL' >Chili<\/option><option value='CN' >Chine<\/option><option value='CX' >Christmas Island<\/option><option value='CY' >Chypre<\/option><option value='CO' >Colombie<\/option><option value='KM' >Comores<\/option><option value='KP' >Cor\u00e9e du Nord<\/option><option value='KR' >Cor\u00e9e du Sud<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatie<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CI' >C\u00f4te-d\u2019Ivoire<\/option><option value='DK' >Danemark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominique<\/option><option value='ER' >Erythr\u00e9e<\/option><option value='ES' >Espagne<\/option><option value='EE' >Estonie<\/option><option value='US' >Etats-Unis (USA)<\/option><option value='FJ' >Fidji<\/option><option value='FI' >Finlande<\/option><option value='FR' >France<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambie<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GD' >Grenade<\/option><option value='GL' >Groenland<\/option><option value='GR' >Gr\u00e8ce<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernesey<\/option><option value='GN' >Guin\u00e9e<\/option><option value='GQ' >Guin\u00e9e \u00e9quatoriale<\/option><option value='GW' >Guin\u00e9e-Bissau<\/option><option value='GY' >Guyane<\/option><option value='GF' >Guyane Fran\u00e7aise<\/option><option value='GE' >G\u00e9orgie<\/option><option value='GS' >G\u00e9orgie du Sud \/ \u00eeles Sandwich<\/option><option value='HT' >Ha\u00efti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hongrie<\/option><option value='IN' >Inde<\/option><option value='ID' >Indon\u00e9sie<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlande<\/option><option value='IS' >Islande<\/option><option value='IL' >Isra\u00ebl<\/option><option value='IT' >Italie<\/option><option value='JM' >Jama\u00efque<\/option><option value='JP' >Japon<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordanie<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kowe\u00eft<\/option><option value='KG' >Kyrgyzstan<\/option><option value='RE' >La R\u00e9union<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonie<\/option><option value='LB' >Liban<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libye<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituanie<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., Chine<\/option><option value='MK' >Mac\u00e9doine<\/option><option value='MG' >Madagascar<\/option><option value='MY' >Malaisie<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malte<\/option><option value='MA' >Maroc<\/option><option value='MQ' >Martinique<\/option><option value='MU' >Maurice<\/option><option value='MR' >Mauritanie<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexique<\/option><option value='FM' >Micron\u00e9sie<\/option><option value='MD' >Moldavie<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolie<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibie<\/option><option value='NR' >Nauru<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norv\u00e8ge<\/option><option value='NC' >Nouvelle-Cal\u00e9donie<\/option><option value='NZ' >Nouvelle-Z\u00e9lande<\/option><option value='NP' >N\u00e9pal<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PA' >Panama<\/option><option value='PG' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='PY' >Paraguay<\/option><option value='NL' >Pays-Bas<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Pologne<\/option><option value='PF' >Polyn\u00e9sie Fran\u00e7aise<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='PE' >P\u00e9rou<\/option><option value='QA' >Qatar<\/option><option value='RO' >Roumanie<\/option><option value='GB' >Royaume-Uni (UK)<\/option><option value='RU' >Russie<\/option><option value='RW' >Rwanda<\/option><option value='CF' >R\u00e9publique Centrafricaine<\/option><option value='DO' >R\u00e9publique Dominicaine<\/option><option value='CZ' >R\u00e9publique Tch\u00e8que<\/option><option value='CG' >R\u00e9publique du Congo (Brazzaville)<\/option><option value='CD' >R\u00e9publique d\u00e9mocratique du Congo (Kinshasa)<\/option><option value='BQ' >Saba, Saint-Eustache et Bonaire<\/option><option value='EH' >Sahara occidental<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='PM' >Saint Pierre et Miquelon<\/option><option value='KN' >Saint-Kitts-et-Nevis<\/option><option value='MF' >Saint-Martin (partie fran\u00e7aise)<\/option><option value='SX' >Saint-Martin (partie n\u00e9erlandaise)<\/option><option value='VC' >Saint-Vincent-et-les-Grenadines<\/option><option value='SH' >Sainte-H\u00e9l\u00e8ne<\/option><option value='LC' >Sainte-Lucie<\/option><option value='SV' >Salvador<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tom\u00e9-et-Principe<\/option><option value='RS' >Serbie<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapour<\/option><option value='SK' >Slovaquie<\/option><option value='SI' >Slov\u00e9nie<\/option><option value='SO' >Somalie<\/option><option value='SD' >Soudan<\/option><option value='SS' >Soudan du Sud<\/option><option value='LK' >Sri Lanka<\/option><option value='CH' >Suisse<\/option><option value='SR' >Suriname<\/option><option value='SE' >Su\u00e8de<\/option><option value='SJ' >Svalbard et Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SY' >Syrie<\/option><option value='SN' >S\u00e9n\u00e9gal<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzanie<\/option><option value='TD' >Tchad<\/option><option value='TF' >Terres Australes Fran\u00e7aises<\/option><option value='PS' >Territoire Palestinien<\/option><option value='IO' >Territoire britannique de l&rsquo;oc\u00e9an Indien<\/option><option value='TH' >Thailande<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinit\u00e9-et-Tobago<\/option><option value='TN' >Tunisie<\/option><option value='TM' >Turkm\u00e9nistan<\/option><option value='TR' >Turquie<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis et Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambie<\/option><option value='ZW' >Zimbabwe<\/option><option value='EG' >\u00c9gypte<\/option><option value='AE' >\u00c9mirats Arabes Unis<\/option><option value='EC' >\u00c9quateur<\/option><option value='ET' >\u00c9thiopie<\/option><option value='BV' >\u00cele Bouvet<\/option><option value='NF' >\u00cele Norfolk<\/option><option value='IM' >\u00cele de Man<\/option><option value='AX' >\u00celes Aland<\/option><option value='KY' >\u00celes Ca\u00efmans<\/option><option value='CC' >\u00celes Cocos<\/option><option value='CK' >\u00celes Cook<\/option><option value='FK' >\u00celes Falkland<\/option><option value='FO' >\u00celes F\u00e9ro\u00e9<\/option><option value='HM' >\u00celes Heard-et-MacDonald<\/option><option value='MH' >\u00celes Marshall<\/option><option value='UM' >\u00celes Mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='SB' >\u00celes Salomon<\/option><option value='TC' >\u00celes Turques et Ca\u00efques<\/option><option value='VI' >\u00celes Vierges am\u00e9ricaines (US)<\/option><option value='VG' >\u00celes Vierges britanniques<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_7' aria-label=\"Groupe sanguin et Rh\u00e9sus\">Groupe sanguin et Rh\u00e9sus<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_3_input_text_7\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric-field_1' aria-label=\"Taille (cm)\">Taille (cm)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_1\" id=\"ff_3_numeric-field_1\" class=\"ff-el-form-control\" data-name=\"numeric-field_1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric-field_4' aria-label=\"Poids (kg)\">Poids (kg)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_4\" id=\"ff_3_numeric-field_4\" class=\"ff-el-form-control\" data-name=\"numeric-field_4\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_6' aria-label=\"Occupation\">Occupation<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_3_input_text_6\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_5' aria-label=\"Education le plus \u00e9lev\u00e9\">Education le plus \u00e9lev\u00e9<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_3_input_text_5\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_3\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1>VOTRE SANTE ET HISTOIRE MEDICALE<\/h1><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_multi_select' aria-label=\"Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostique de:\">Avez-vous d\u00e9j\u00e0 \u00e9t\u00e9 diagnostique de:<\/label><\/div><div class='ff-el-input--content'><select name=\"multi_select[]\" id=\"ff_3_multi_select\" class=\"ff-el-form-control  ff_has_multi_select\" multiple=\"1\" data-name=\"multi_select\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\"><option value=\"None\"  >Aucun<\/option><option value=\"Other\"  >Autre<\/option><option value=\"AIDS \"  >VIH<\/option><option value=\"Cancer\"  >Cancer<\/option><option value=\"Autoimmune disorders\"  >Autoimmune disorders<\/option><option value=\"Birth defect\"  >Malformations cong\u00e9nitales<\/option><option value=\"DES syndrome\"  >Syndrome du di\u00e9thylstilbestrol<\/option><option value=\"Endometriosis\"  >Endom\u00e9triose<\/option><option value=\"Extremely brief menstrual cycles\"  >Menstruations tr\u00e8s br\u00e8ves<\/option><option value=\"Failure of eggs to mature\"  >\u00c9chec de la maturation des ovacytes<\/option><option value=\"Fibroids\"  >Fibromes<\/option><option value=\"Hormone imbalance\"  >D\u00e9s\u00e9quilibre hormonal<\/option><option value=\"Implantation Failure\"  >\u00c9chec d'implantation<\/option><option value=\"Multiple miscarriages\"  >Multiples fausses couches<\/option><option value=\"Ovulation failure\"  >\u00c9chec de l'ovulation<\/option><option value=\"Painful menstruation\"  >Menstruations douloureuses<\/option><option value=\"PCOS\"  >SOPK<\/option><option value=\"Polyps in uterus\"  >Polypes dans l'ut\u00e9rus<\/option><option value=\"POI (Primary Ovary Insufficiency)\"  >IPO (Insuffisance Ovaire Primaire)<\/option><option value=\"Premature ovarian failure\"  >Insuffisance ovarienne pr\u00e9matur\u00e9e<\/option><option value=\"Tumor or cyst\"  >Tumeur ou kyste<\/option><option value=\"Thyroid gland problems\"  >Probl\u00e8mes de glande thyro\u00efde<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_3' aria-label=\"Avez-vous d\u00e9j\u00e0 accouch\u00e9\">Avez-vous d\u00e9j\u00e0 accouch\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_3\" id=\"ff_3_dropdown_3\" class=\"ff-el-form-control\" data-name=\"dropdown_3\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_message' aria-label=\"Si oui, donnez des d\u00e9tails\">Si oui, donnez des d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"message\" id=\"ff_3_message\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_6' aria-label=\"Avez-vous d\u00e9j\u00e0 subi une intervention chirurgicale\">Avez-vous d\u00e9j\u00e0 subi une intervention chirurgicale<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_6\" id=\"ff_3_dropdown_6\" class=\"ff-el-form-control\" data-name=\"dropdown_6\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_message_2' aria-label=\"Si oui, donnez des d\u00e9tails\">Si oui, donnez des d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"message_2\" id=\"ff_3_message_2\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_2\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_message_1' aria-label=\"Fournissez votre historique de traitement\">Fournissez votre historique de traitement<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"message_1\" id=\"ff_3_message_1\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_1\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_multi_select_1' aria-label=\"S\u00e9lectionnez tout ce qui s&#039;applique \u00e0 votre foyer\">S\u00e9lectionnez tout ce qui s'applique \u00e0 votre foyer<\/label><\/div><div class='ff-el-input--content'><select name=\"multi_select_1[]\" id=\"ff_3_multi_select_1\" class=\"ff-el-form-control  ff_has_multi_select\" multiple=\"1\" data-name=\"multi_select_1\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"I smoke\"  >je fume<\/option><option value=\"I use recreational drugs\"  >Je prend des stup\u00e9fiants<\/option><option value=\"I drink\"  >Je bois<\/option><option value=\"Partner smokes\"  >Mon partenaire fume<\/option><option value=\"Partner uses recreational drugs\"  >mon partenaire prend des stup\u00e9fiants<\/option><option value=\"Partner drink\"  >Mon partenaire boit<\/option><option value=\"None\"  >Aucun<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_4' aria-label=\"Est-ce que vous ou votre partenaire prenez des m\u00e9dicaments\">Est-ce que vous ou votre partenaire prenez des m\u00e9dicaments<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_4\" id=\"ff_3_dropdown_4\" class=\"ff-el-form-control\" data-name=\"dropdown_4\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_message_3' aria-label=\"Si oui, donnez des d\u00e9tails\">Si oui, donnez des d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"message_3\" id=\"ff_3_message_3\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_3\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_8' aria-label=\"Vous ou votre partenaire avez une maladie g\u00e9n\u00e9tique\">Vous ou votre partenaire avez une maladie g\u00e9n\u00e9tique<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_8\" id=\"ff_3_dropdown_8\" class=\"ff-el-form-control\" data-name=\"dropdown_8\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_message_4' aria-label=\"Si oui, donnez des d\u00e9tails\">Si oui, donnez des d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"message_4\" id=\"ff_3_message_4\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_4\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_9' aria-label=\"Avez-vous ou votre partenaire \u00e9t\u00e9 trait\u00e9 pour la d\u00e9pression\">Avez-vous ou votre partenaire \u00e9t\u00e9 trait\u00e9 pour la d\u00e9pression<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_9\" id=\"ff_3_dropdown_9\" class=\"ff-el-form-control\" data-name=\"dropdown_9\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_message_5' aria-label=\"Si oui, donnez des d\u00e9tails\">Si oui, donnez des d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"message_5\" id=\"ff_3_message_5\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_5\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-3_4\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1>VOTRE PARCOURS GPA<\/h1><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_datetime_2' aria-label=\"Date de la derni\u00e8re menstruation (le cas \u00e9ch\u00e9ant)\">Date de la derni\u00e8re menstruation (le cas \u00e9ch\u00e9ant)<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Last date of menstruation (if applicable) Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d-M-y' type=\"text\" name=\"datetime_2\" id=\"ff_3_datetime_2\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_2\"  aria-invalid='false' aria-required=\"false\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime_3' aria-label=\"Quand souhaitez-vous commencer le traitement\">Quand souhaitez-vous commencer le traitement<\/label><\/div><div class='ff-el-input--content'><input  aria-label='When would you like to start the treatment Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime_3\" id=\"ff_3_datetime_3\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime_3\"  aria-invalid='false' aria-required=\"true\"><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_10' aria-label=\"Souhaitez-vous avoir des jumeaux\">Souhaitez-vous avoir des jumeaux<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_10\" id=\"ff_3_dropdown_10\" class=\"ff-el-form-control\" data-name=\"dropdown_10\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_11' aria-label=\"Souhaitez-vous avoir plusieurs m\u00e8res porteuses \u00e0 la fois\">Souhaitez-vous avoir plusieurs m\u00e8res porteuses \u00e0 la fois<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_11\" id=\"ff_3_dropdown_11\" class=\"ff-el-form-control\" data-name=\"dropdown_11\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown_12' aria-label=\"Souhaitez-vous avoir la s\u00e9lection du sexe (des frais suppl\u00e9mentaires peuvent s&#039;appliquer)\">Souhaitez-vous avoir la s\u00e9lection du sexe (des frais suppl\u00e9mentaires peuvent s'appliquer)<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_12\" id=\"ff_3_dropdown_12\" class=\"ff-el-form-control\" data-name=\"dropdown_12\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><option value=\"\">- Select -<\/option><option value=\"Yes\"  >Oui<\/option><option value=\"No\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_dropdown_7' aria-label=\"O\u00f9 souhaitez-vous que la naissance ait lieu\">O\u00f9 souhaitez-vous que la naissance ait lieu<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_7\" id=\"ff_3_dropdown_7\" class=\"ff-el-form-control\" data-name=\"dropdown_7\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"false\"><option value=\"\">- Select -<\/option><option value=\"Austria\"  >Autriche<\/option><option value=\"Cyprus\"  >Chypre<\/option><option value=\"Czech Republic\"  >R\u00e9publique Tch\u00e8que<\/option><option value=\"Ukraine\"  >Ukraine<\/option><option value=\"Another EU county\"  >Un autre pays de l'UE<\/option><option value=\"Other\"  >Autre<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_message_6' aria-label=\"Si oui, donnez des d\u00e9tails\">Si oui, donnez des d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"message_6\" id=\"ff_3_message_6\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_6\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_message_7' aria-label=\"Listez vos attentes pendant le traitement\">Listez vos attentes pendant le traitement<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"message_7\" id=\"ff_3_message_7\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_7\" ><\/textarea><\/div><\/div><div class=\"ff-el-group  has-conditions ff-el-section-break  ff_left\" data-name=\"section_break-3_5\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1>CARACT\u00c9RISTIQUES DE LA DONNEUSE (DU DONNEUR)<\/h1><\/div><hr \/><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_7' aria-label=\"Taille (cm)\">Taille (cm)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_7\" id=\"ff_3_numeric-field_7\" class=\"ff-el-form-control\" data-name=\"numeric-field_7\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_numeric-field_8' aria-label=\"Poids (kg)\">Poids (kg)<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_8\" id=\"ff_3_numeric-field_8\" class=\"ff-el-form-control\" data-name=\"numeric-field_8\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_description' aria-label=\"Indiquez les pays d&#039;origines requis\">Indiquez les pays d'origines requis<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"description\" id=\"ff_3_description\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description\" ><\/textarea><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_9' aria-label=\"Couleur des yeux\">Couleur des yeux<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_3_input_text_9\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_10' aria-label=\"Couleur de peau\">Couleur de peau<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_3_input_text_10\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_15' aria-label=\"Sp\u00e9cificit\u00e9 de la couleur de peau\">Sp\u00e9cificit\u00e9 de la couleur de peau<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_15\" class=\"ff-el-form-control\" data-name=\"input_text_15\" id=\"ff_3_input_text_15\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_14' aria-label=\"Couleur des cheveux\">Couleur des cheveux<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_14\" class=\"ff-el-form-control\" data-name=\"input_text_14\" id=\"ff_3_input_text_14\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_13' aria-label=\"Type de cheveux\">Type de cheveux<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_3_input_text_13\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_12' aria-label=\"Education\">Education<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" data-name=\"input_text_12\" id=\"ff_3_input_text_12\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_11' aria-label=\"Personnalit\u00e9\">Personnalit\u00e9<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" data-name=\"input_text_11\" id=\"ff_3_input_text_11\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_16' aria-label=\"Passe-temps\/Projets\">Passe-temps\/Projets<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_16\" class=\"ff-el-form-control\" data-name=\"input_text_16\" id=\"ff_3_input_text_16\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label 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