{"id":426,"date":"2017-03-26T15:11:02","date_gmt":"2017-03-26T13:11:02","guid":{"rendered":"http:\/\/sur.weenwin.co.uk\/?page_id=426"},"modified":"2023-08-18T16:04:07","modified_gmt":"2023-08-18T14:04:07","slug":"contact-us","status":"publish","type":"page","link":"https:\/\/www.angelsfriend.com\/fr\/contact-us\/","title":{"rendered":"Contact"},"content":{"rendered":"<div class=\"wp-blockade\"><!--themify_builder_content-->\n<div id=\"themify_builder_content-426\" data-postid=\"426\" class=\"themify_builder_content themify_builder_content-426 themify_builder tf_clear\">\n                    <div  data-lazy=\"1\" class=\"module_row themify_builder_row tb_ba3092f 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_7d7bfa6 first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_4610344  repeat\" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <p>Veuillez remplir le formulaire de ci-dessous pour commencer votre parcours.<\/p>    <\/div>\n<\/div>\n<!-- \/module text -->        <\/div>\n                        <\/div>\n        <\/div>\n                        <div  data-lazy=\"1\" class=\"module_row themify_builder_row tb_ttyw849 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_9hmo849 first\">\n                    <!-- module accordion -->\n<div  class=\"module module-accordion tb_jhk4849\" data-behavior=\"toggle\" data-lazy=\"1\">\n    \n    <ul class=\"ui module-accordion   light-blue\">\n            <li>\n            <div class=\"accordion-title tf_rel\">\n                <a href=\"#acc-jhk4849-0\" class=\"tb_title_accordion\" aria-controls=\"acc-jhk4849-0-content\" aria-expanded=\"false\">\n                                                            <span class=\"accordion-title-wrap\">START YOUR IVF HERE<\/span>                <\/a>\n            <\/div><!-- .accordion-title -->\n            <div id=\"acc-jhk4849-0-content\" data-id=\"acc-jhk4849-0\" aria-hidden=\"true\" class=\"accordion-content tf_hide tf_clearfix\">\n                                    <div class=\"tb_text_wrap\">\n                        <div class='fluentform ff-default fluentform_wrapper_7 ffs_default_wrap'><form data-form_id=\"7\" id=\"fluentform_7\" class=\"frm-fluent-form fluent_form_7 ff-el-form-left ff_form_instance_7_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_7_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;\">IVF FORM<\/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=\"223\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type='hidden' name='__fluent_form_embded_post_id' value='426' \/><input type=\"hidden\" id=\"_fluentform_7_fluentformnonce\" name=\"_fluentform_7_fluentformnonce\" value=\"d841c181b8\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/426\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-7_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_7_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_7_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=\"IVF with own egg\"  >IVF with own egg<\/option><option value=\"IVF with egg donor\"  >IVF with egg donor<\/option><option value=\"Other\"  >Autre<\/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_7_input_text_17' aria-label=\"Give details of service\">Give details of service<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_17\" class=\"ff-el-form-control\" data-name=\"input_text_17\" id=\"ff_7_input_text_17\"  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_7_dropdown_1' aria-label=\"Statut matrimonial\">Statut matrimonial<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_7_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 Woman\"  >Single Woman<\/option><option value=\"Unmarried couple\"  >Couple pas mari\u00e9<\/option><option value=\"Married couple\"  >Married couple<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown' aria-label=\"Titre\">Titre<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_7_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_7_names_first_name_' >Pr\u00e9nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_7_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_7_names_last_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_address_1_city_' aria-label=\"Ville\">Ville<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_7_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_7_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_7_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_7_address_1_country_' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_7_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_7_country-list_1' aria-label=\"Nationalit\u00e9\">Nationalit\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list_1\" id=\"ff_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_input_text_4\"  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_7_dropdown_13' aria-label=\"Do you have a criminal record\">Do you have a criminal record<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_13\" id=\"ff_7_dropdown_13\" class=\"ff-el-form-control\" data-name=\"dropdown_13\" 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 ff-el-section-break  ff_left\" data-name=\"section_break-7_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_7_dropdown_2' aria-label=\"Titre\">Titre<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_7_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_7_names_1_first_name_' >Pr\u00e9nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_7_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_7_names_1_last_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[last_name]\" id=\"ff_7_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_7_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_7_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_7_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_7_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_7_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_7_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_7_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_7_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_7_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_7_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_7_address_4_city_' aria-label=\"Ville\">Ville<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_4[city]\" id=\"ff_7_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_7_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_7_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_7_address_4_country_' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"address_4[country]\" id=\"ff_7_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_7_country-list' aria-label=\"Nationalit\u00e9\">Nationalit\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_input_text_5\"  aria-invalid=\"false\" aria-required=\"false\"><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_dropdown_14' aria-label=\"Do you have a criminal record\">Do you have a criminal record<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_14\" id=\"ff_7_dropdown_14\" class=\"ff-el-form-control\" data-name=\"dropdown_14\" 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_7_description_2' aria-label=\"Provide the list of medical conditions of partner\">Provide the list of medical conditions of partner<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"description_2\" id=\"ff_7_description_2\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_2\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-7_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_7_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_7_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 has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_7_input_text_18' aria-label=\"Give details\">Give details<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_18\" class=\"ff-el-form-control\" data-name=\"input_text_18\" id=\"ff_7_input_text_18\"  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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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-7_4\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1>YOUR TREATMENT JOURNEY<\/h1><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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 has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_7_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_7_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_7_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_7_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-7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_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_7_input_text_16\"  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_7_description_1' aria-label=\"Autres d\u00e9tails\">Autres d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"description_1\" id=\"ff_7_description_1\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Envoyez<\/button><\/div><\/fieldset><input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form><div id='fluentform_7_errors' class='ff-errors-in-stack ff_form_instance_7_1 ff-form-loading_errors ff_form_instance_7_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_7_1 = {\"id\":\"7\",\"settings\":{\"layout\":{\"labelPlacement\":\"left\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"stackToBottom\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_7_1\",\"form_id_selector\":\"fluentform_7\",\"rules\":{\"dropdown_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"input_text_17\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown_1\":{\"required\":{\"value\":true,\"message\":\"This 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                        <\/div><!-- .accordion-content -->\n        <\/li>\n        <\/ul>\n\n<\/div><!-- \/module accordion -->        <\/div>\n                        <\/div>\n        <\/div>\n                        <div  data-lazy=\"1\" class=\"module_row themify_builder_row tb_sx0r925 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_lgqm925 first\">\n                    <!-- module accordion -->\n<div  class=\"module module-accordion tb_7wqn925\" data-behavior=\"toggle\" data-lazy=\"1\">\n    \n    <ul class=\"ui module-accordion   light-blue\">\n            <li>\n            <div class=\"accordion-title tf_rel\">\n                <a href=\"#acc-7wqn925-0\" class=\"tb_title_accordion\" aria-controls=\"acc-7wqn925-0-content\" aria-expanded=\"false\">\n                                                            <span class=\"accordion-title-wrap\">FORMULAIRE POUR TOUT AUTRE PATIENT<\/span>                <\/a>\n            <\/div><!-- .accordion-title -->\n            <div id=\"acc-7wqn925-0-content\" data-id=\"acc-7wqn925-0\" aria-hidden=\"true\" class=\"accordion-content tf_hide tf_clearfix\">\n                                    <div class=\"tb_text_wrap\">\n                        <div class='fluentform ff-default fluentform_wrapper_6 ffs_default_wrap'><form data-form_id=\"6\" id=\"fluentform_6\" class=\"frm-fluent-form fluent_form_6 ff-el-form-left ff_form_instance_6_2 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_6_2\" 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;\">MEDICAL FORM<\/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_2\" name=\"ak_js\" value=\"165\"\/><script>document.getElementById( \"ak_js_2\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type='hidden' name='__fluent_form_embded_post_id' value='426' \/><input type=\"hidden\" id=\"_fluentform_6_fluentformnonce\" name=\"_fluentform_6_fluentformnonce\" value=\"d841c181b8\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/426\" \/><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-6_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_6_2_input_text_4' aria-label=\"Service\">Service<\/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_6_2_input_text_4\"  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_6_2_dropdown' aria-label=\"Titre\">Titre<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_6_2_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=\"Miss\"  >Miss<\/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_6_2_names_first_name_' >Pr\u00e9nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_6_2_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_6_2_names_last_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_address_1_city_' aria-label=\"Ville\">Ville<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_6_2_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_6_2_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_6_2_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_6_2_address_1_country_' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_6_2_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_6_2_country-list_1' aria-label=\"Nationalit\u00e9\">Nationalit\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list_1\" id=\"ff_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_input_text_2\"  aria-invalid=\"false\" aria-required=\"true\"><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-6_2\" ><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 ff-el-is-required asterisk-right\"><label for='ff_6_2_message_1' aria-label=\"Donnez votre histoire m\u00e9dicale\">Donnez votre histoire m\u00e9dicale<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"true\" name=\"message_1\" id=\"ff_6_2_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_6_2_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_6_2_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_6_2_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_6_2_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_6_2_multi_select_1' aria-label=\"Fumez-vous\">Fumez-vous<\/label><\/div><div class='ff-el-input--content'><select name=\"multi_select_1[]\" id=\"ff_6_2_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=\"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_6_2_multi_select_2' aria-label=\"Consommez-vous de l&#039;alcool\">Consommez-vous de l'alcool<\/label><\/div><div class='ff-el-input--content'><select name=\"multi_select_2[]\" id=\"ff_6_2_multi_select_2\" class=\"ff-el-form-control  ff_has_multi_select\" multiple=\"1\" data-name=\"multi_select_2\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=\"true\"><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_6_2_dropdown_4' aria-label=\"Prenez-vous des m\u00e9dicaments\">Prenez-vous des m\u00e9dicaments<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_4\" id=\"ff_6_2_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_6_2_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_6_2_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_6_2_dropdown_8' aria-label=\"Avez-vous des allergies\">Avez-vous des allergies<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_8\" id=\"ff_6_2_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_6_2_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_6_2_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_6_2_dropdown_9' aria-label=\"Avez-vous \u00e9t\u00e9 trait\u00e9 pour la d\u00e9pression\">Avez-vous \u00e9t\u00e9 trait\u00e9 pour la d\u00e9pression<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_9\" id=\"ff_6_2_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_6_2_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_6_2_message_5\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_5\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_6_2_message_8' aria-label=\"Plus d&#039;information (sur votre sant\u00e9)\">Plus d'information (sur votre sant\u00e9)<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"message_8\" id=\"ff_6_2_message_8\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_8\" ><\/textarea><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-6_3\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><h1>YOUR TREATMENT<\/h1><\/div><hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_2_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_6_2_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_6_2_country-list' aria-label=\"Premier choix de traitement\">Premier choix de traitement<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_6_2_country-list\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-name=\"country-list\" 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_6_2_country-list_2' aria-label=\"Second choix de traitement\">Second choix de traitement<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list_2\" id=\"ff_6_2_country-list_2\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-name=\"country-list_2\" 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_6_2_country-list_3' aria-label=\"Troisi\u00e8me choix de traitement\">Troisi\u00e8me choix de traitement<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list_3\" id=\"ff_6_2_country-list_3\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-name=\"country-list_3\" 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 asterisk-right\"><label for='ff_6_2_dropdown_7' aria-label=\"Avez-vous des besoins speciaux\">Avez-vous des besoins speciaux<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_7\" id=\"ff_6_2_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=\"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_6_2_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_6_2_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 ff-el-is-required asterisk-right\"><label for='ff_6_2_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=\"true\" name=\"message_7\" id=\"ff_6_2_message_7\" class=\"ff-el-form-control\" rows=\"4\" cols=\"2\" data-name=\"message_7\" ><\/textarea><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Consentement de partage des donn\u00e9es\">Consentement de partage des donn\u00e9es<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"checkbox_e3f730d65eda359b3dd0efccb0454f07\"><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"I fully give consent that Angels Friend can share my information (personal and medical) to all relevant institutions to find the best treatments for my condition.\"  id='checkbox_e3f730d65eda359b3dd0efccb0454f07' aria-label='Je donne mon consentement que Angels Friend peut partager mes informations (personnelles et m\u00e9dicales) avec toutes institutions, pour trouver les meilleurs traitement pour ma conditions' aria-invalid='false' aria-required=\"true\"> <span>Je donne mon consentement que Angels Friend peut partager mes informations (personnelles et m\u00e9dicales) avec toutes institutions, pour trouver les meilleurs traitement pour ma conditions<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Confirmation des informations\">Confirmation des informations<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=\"checkbox_1_affb5b581cf4179ff6c69af7c4a33a83\"><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"All information provided is correct and accurate to the best of my knowledge. I understand that false information or documentations may result in the cancellation of my treatment\/application without refund or may result in additional payable cost.\"  id='checkbox_1_affb5b581cf4179ff6c69af7c4a33a83' aria-label='Je confirme que toutes les informations ci-dessus sont correctes et pr\u00e9cises. Je comprends que des informations ou documentations frauduleuses pourraient annuler mon traitement\/application et sans remboursement quelconque ou pourrait engendrer des co\u00fbts additionnels' aria-invalid='false' aria-required=\"true\"> <span>Je confirme que toutes les informations ci-dessus sont correctes et pr\u00e9cises. Je comprends que des informations ou documentations frauduleuses pourraient annuler mon traitement\/application et sans remboursement quelconque ou pourrait engendrer des co\u00fbts additionnels<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Envoyez<\/button><\/div><\/fieldset><input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form><div id='fluentform_6_errors' class='ff-errors-in-stack ff_form_instance_6_2 ff-form-loading_errors ff_form_instance_6_2_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_6_2 = {\"id\":\"6\",\"settings\":{\"layout\":{\"labelPlacement\":\"left\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"stackToBottom\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_6_2\",\"form_id_selector\":\"fluentform_6\",\"rules\":{\"input_text_4\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"names[first_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[last_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"datetime\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"numeric-field_6\":{\"required\":{\"value\":true,\"message\":\"This field is 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required\"}}},\"debounce_time\":300,\"conditionals\":{\"message_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_6\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_3\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_4\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_4\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_8\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_5\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_9\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_6\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_7\",\"value\":\"Yes\",\"operator\":\"=\"}]}}};\n                    <\/script>\n                            <\/div>\n                            <\/div><!-- .accordion-content -->\n        <\/li>\n        <\/ul>\n\n<\/div><!-- \/module accordion -->        <\/div>\n                        <\/div>\n        <\/div>\n                        <div  data-lazy=\"1\" class=\"module_row themify_builder_row tb_6290e5d 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_7c86829 first\">\n                    <!-- module accordion -->\n<div  class=\"module module-accordion tb_d59c916\" data-behavior=\"toggle\" data-lazy=\"1\">\n    \n    <ul class=\"ui module-accordion   light-blue\">\n            <li>\n            <div class=\"accordion-title tf_rel\">\n                <a href=\"#acc-d59c916-0\" class=\"tb_title_accordion\" aria-controls=\"acc-d59c916-0-content\" aria-expanded=\"false\">\n                                                            <span class=\"accordion-title-wrap\">START YOUR SURROGACY JOURNEY HERE<\/span>                <\/a>\n            <\/div><!-- .accordion-title -->\n            <div id=\"acc-d59c916-0-content\" data-id=\"acc-d59c916-0\" aria-hidden=\"true\" class=\"accordion-content tf_hide tf_clearfix\">\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_3 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_3\" 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_3\" name=\"ak_js\" value=\"53\"\/><script>document.getElementById( \"ak_js_3\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><input type='hidden' name='__fluent_form_embded_post_id' value='426' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"d841c181b8\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/fr\/wp-json\/wp\/v2\/pages\/426\" \/><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_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_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_3_dropdown_1' aria-label=\"Statut matrimonial\">Statut matrimonial<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_1\" id=\"ff_3_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_3_dropdown' aria-label=\"Titre\">Titre<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_3_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_3_names_first_name_' >Pr\u00e9nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_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_3_names_last_name_' >Nom<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_3_address_1_country_' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_3_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_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_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_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_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_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_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_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_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_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_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_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_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_3_dropdown_2' aria-label=\"Titre\">Titre<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown_2\" id=\"ff_3_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_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_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_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_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_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_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_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_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_3_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_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_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_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_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_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_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_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_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_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_3_address_4_country_' aria-label=\"Pays\">Pays<\/label><\/div><div class='ff-el-input--content'><select name=\"address_4[country]\" id=\"ff_3_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_3_country-list' aria-label=\"Nationalit\u00e9\">Nationalit\u00e9<\/label><\/div><div class='ff-el-input--content'><select name=\"country-list\" id=\"ff_3_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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_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 asterisk-right\"><label for='ff_3_3_description_1' aria-label=\"Autres d\u00e9tails\">Autres d\u00e9tails<\/label><\/div><div class='ff-el-input--content'><textarea aria-invalid=\"false\" aria-required=\"false\" name=\"description_1\" id=\"ff_3_3_description_1\" class=\"ff-el-form-control\" rows=\"3\" cols=\"2\" data-name=\"description_1\" ><\/textarea><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Envoyez<\/button><\/div><\/fieldset><input type=\"hidden\" name=\"trp-form-language\" value=\"fr\"\/><\/form><div id='fluentform_3_errors' class='ff-errors-in-stack ff_form_instance_3_3 ff-form-loading_errors ff_form_instance_3_3_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_3_3 = {\"id\":\"3\",\"settings\":{\"layout\":{\"labelPlacement\":\"left\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"stackToBottom\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_3_3\",\"form_id_selector\":\"fluentform_3\",\"rules\":{\"dropdown_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"names[first_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names[last_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"datetime\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"numeric-field_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"input_text\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"address_1[address_line_1]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[address_line_2]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"address_1[city]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"address_1[state]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_1[zip]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"address_1[country]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"country-list_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"input_text_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"numeric-field_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"numeric-field_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"input_text_2\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"input_text_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"dropdown_2\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"names_1[first_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"names_1[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"names_1[last_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"datetime_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"numeric-field\":{\"required\":{\"value\":true,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"email\":{\"required\":{\"value\":true,\"message\":\"This field is required\"},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\"}},\"address_4[address_line_1]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_4[address_line_2]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_4[city]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_4[state]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_4[zip]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"address_4[country]\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"country-list\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"input_text_7\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"numeric-field_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"numeric-field_4\":{\"required\":{\"value\":true,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"input_text_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"input_text_5\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"multi_select\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"dropdown_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"message\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"dropdown_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"message_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"message_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"multi_select_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown_4\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"message_3\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"dropdown_8\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"message_4\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"dropdown_9\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"message_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"datetime_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"datetime_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown_10\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown_11\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown_12\":{\"required\":{\"value\":true,\"message\":\"This field is required\"}},\"dropdown_7\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"message_6\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"message_7\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"numeric-field_7\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"numeric-field_8\":{\"required\":{\"value\":false,\"message\":\"This field is required\"},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\"},\"min\":{\"value\":\"\",\"message\":\"Minimum value is \"},\"max\":{\"value\":\"\",\"message\":\"Maximum value is \"},\"digits\":{\"value\":\"\",\"message\":\"The number of digits has to be \"}},\"description\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_9\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_10\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_15\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_14\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_13\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_12\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_11\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"input_text_16\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}},\"description_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\"}}},\"debounce_time\":300,\"conditionals\":{\"section_break-3_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"dropdown_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"names_1\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"datetime_1\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"numeric-field\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"email\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Single\",\"operator\":\"!=\"}]},\"address_4\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"country-list\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Single\",\"operator\":\"!=\"}]},\"input_text_7\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"numeric-field_1\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"numeric-field_4\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"input_text_6\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"input_text_5\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_1\",\"value\":\"Married\",\"operator\":\"=\"},{\"field\":\"dropdown_1\",\"value\":\"Unmarried couple\",\"operator\":\"=\"}]},\"message\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_3\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_6\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_3\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_4\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_4\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_8\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_5\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_9\",\"value\":\"Yes\",\"operator\":\"=\"}]},\"message_6\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_7\",\"value\":\"Another EU county\",\"operator\":\"=\"},{\"field\":\"dropdown_7\",\"value\":\"Other\",\"operator\":\"=\"}]},\"section_break-3_5\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"numeric-field_7\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"numeric-field_8\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"description\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_9\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_10\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_15\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_14\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_13\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_12\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_11\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]},\"input_text_16\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"}]},\"description_1\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with egg donor\",\"operator\":\"=\"},{\"field\":\"dropdown_5\",\"value\":\"Surrogacy with sperm donor\",\"operator\":\"=\"}]}}};\n                    <\/script>\n                            <\/div>\n                            <\/div><!-- .accordion-content -->\n        <\/li>\n        <\/ul>\n\n<\/div><!-- \/module accordion -->        <\/div>\n                        <\/div>\n        <\/div>\n                        <div  data-lazy=\"1\" class=\"module_row themify_builder_row tb_3ff7e0b 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_009e6f2 first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_4d9b8ff  repeat\" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <h2>\u00a0<\/h2>\n<h2 style=\"text-align: center;\">Contact<\/h2>    <\/div>\n<\/div>\n<!-- \/module text -->        <\/div>\n                        <\/div>\n        <\/div>\n                        <div  data-lazy=\"1\" class=\"module_row themify_builder_row tb_0ba4fd1 tf_w\">\n                        <div class=\"row_inner col_align_top tb_col_count_2 tf_box tf_rel\">\n                        <div  data-lazy=\"1\" class=\"module_column tb-column col4-2 tb_b9fb53a first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_6a15314  repeat\" data-lazy=\"1\">\n    <h3 class=\"module-title\">Nos d\u00e9tails<\/h3>    <div  class=\"tb_text_wrap\">\n        <p><span style=\"font-size: 12pt;\">D\u00e9tails bancaires<\/span><br \/><span style=\"font-size: 12pt;\">Fio Bank (Euro account)<\/span><br \/><span style=\"font-size: 12pt;\">Iban: CZ0920100000002401533202<\/span><br \/><span style=\"font-size: 12pt;\">BIC\/SWIFT: FIOBCZPPXXX<\/span><\/p>\n<p>\u00a0<\/p>\n<p>\u00a0<\/p>\n<p>\u00a0<\/p>    <\/div>\n<\/div>\n<!-- \/module text -->        <\/div>\n                    <div  data-lazy=\"1\" class=\"module_column tb-column col4-2 tb_479f7dd last\">\n                    <!-- module divider -->\n<div  class=\"module tf_mw module-divider tb_b4c90da solid  divider-custom divider-left\" style=\"border-width: 1px;border-color: #d1d1d1;margin-top: 5px;margin-bottom: 13px;max-width: 50px;\" data-lazy=\"1\">\n    <\/div>\n<!-- \/module divider -->\n<!-- module icon -->\n<div  class=\"module module-icon tb_f911810  normal circle icon_vertical\" data-lazy=\"1\">\n            <div class=\"module-icon-item\">\n                                                                <em class=\"tf_box\"><svg  class=\"tf_fa tf-far-envelope\" aria-hidden=\"true\"><use href=\"#tf-far-envelope\"><\/use><\/svg><\/em>\n                                                                            <span>info@angelsfriend.com<\/span>\n                                                            <\/div>\n            <div class=\"module-icon-item\">\n                                                                <em class=\"tf_box\"><svg  class=\"tf_fa tf-fas-phone\" aria-hidden=\"true\"><use href=\"#tf-fas-phone\"><\/use><\/svg><\/em>\n                                                                            <span>+4420 3950 9372<\/span>\n                                                            <\/div>\n            <div class=\"module-icon-item\">\n                                                                <em class=\"tf_box\"><svg  class=\"tf_fa tf-fas-mobile\" aria-hidden=\"true\"><use href=\"#tf-fas-mobile\"><\/use><\/svg><\/em>\n                                                                            <span>+420 777 159 622 (WhatsApp & Viber)<\/span>\n                                                            <\/div>\n            <div class=\"module-icon-item\">\n                                                                <em class=\"tf_box\"><svg  class=\"tf_fa tf-fas-mobile\" aria-hidden=\"true\"><use href=\"#tf-fas-mobile\"><\/use><\/svg><\/em>\n                                                                            <span>Skype: Angels Friend Surrogacy<\/span>\n                                                            <\/div>\n    <\/div>\n<!-- \/module icon -->\n        <div  data-lazy=\"1\" class=\"module_subrow themify_builder_sub_row tf_w col_align_top gutter-none tb_col_count_2 tb_f013b02\">\n                <div  data-lazy=\"1\" class=\"module_column sub_column tb_a8ac0de first\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_ca2ac63  repeat\" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <h4><strong>Adresse de meeting<\/strong><\/h4>    <\/div>\n<\/div>\n<!-- \/module text --><!-- module text -->\n<div  class=\"module module-text tb_49e410e  repeat\" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <p>Pobrezni 249\/46<br \/>Prague 8, 18600<br \/>R\u00e9publique Tch\u00e8que<\/p>    <\/div>\n<\/div>\n<!-- \/module text --><!-- module divider -->\n<div  class=\"module tf_mw module-divider tb_frqx070 solid  divider-custom divider-left\" style=\"border-width: 1px;border-color: #d1d1d1;margin-top: 5px;margin-bottom: 13px;max-width: 50px;\" data-lazy=\"1\">\n    <\/div>\n<!-- \/module divider -->\n        <\/div>\n                    <div  data-lazy=\"1\" class=\"module_column sub_column tb_2da384c last\">\n                    <!-- module text -->\n<div  class=\"module module-text tb_spzk071  repeat\" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <h4><strong>Addresse d'enr\u00e9gistrement<\/strong><\/h4>    <\/div>\n<\/div>\n<!-- \/module text --><!-- module text -->\n<div  class=\"module module-text tb_s4cu000  repeat\" data-lazy=\"1\">\n        <div  class=\"tb_text_wrap\">\n        <p>Dopravni 500\/9<br \/>Prague 10, 10400<br \/>R\u00e9publique Tch\u00e8que<\/p>    <\/div>\n<\/div>\n<!-- \/module text --><!-- module divider -->\n<div  class=\"module tf_mw module-divider tb_f4c22c2 solid  divider-custom divider-left\" style=\"border-width: 1px;border-color: #d1d1d1;margin-top: 5px;margin-bottom: 13px;max-width: 50px;\" data-lazy=\"1\">\n    <\/div>\n<!-- \/module divider -->\n        <\/div>\n                    <\/div>\n        <!-- module divider -->\n<div  class=\"module tf_mw module-divider tb_vlz4003 solid  divider-custom divider-left\" style=\"border-width: 1px;border-color: #d1d1d1;margin-top: 5px;margin-bottom: 13px;max-width: 50px;\" data-lazy=\"1\">\n    <\/div>\n<!-- \/module divider -->\n        <\/div>\n                        <\/div>\n        <\/div>\n        <\/div>\n<!--\/themify_builder_content--><\/div>","protected":false},"excerpt":{"rendered":"Kindly fill out the surrogacy form to start your journey. SURROGACY FORM PATIENT FORM \u00a0 Contact details Our details Bank detailsFio Bank (Euro account)Iban: CZ0920100000002401533202BIC\/SWIFT: FIOBCZPPXXX \u00a0 \u00a0 \u00a0 info@angelsfriend.com +4420 3950 9372 +420 777 159 622 (WhatsApp &#038; Viber) Skype: Angels Friend Surrogacy Meeting address Pobrezni 249\/46Prague 8, 18600Czech Republic Registered address Dopravni 500\/9Prague<p><a href=\"https:\/\/www.angelsfriend.com\/fr\/contact-us\/\" class=\"more-link themebutton\">Read More<\/a><\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-426","page","type-page","status-publish","hentry"],"builder_content":"<p>Kindly fill out the surrogacy form to start your journey.<\/p>\n<ul><li><h4>START YOUR IVF HERE<\/h4><p>[fluentform id=\"7\"]<\/p><\/li><\/ul>\n<ul><li><h4>PATIENT FORM<\/h4><p>[fluentform id=\"6\"]<\/p><\/li><\/ul>\n<ul><li><h4>START YOUR SURROGACY JOURNEY HERE<\/h4><p>[fluentform id=\"3\"]<\/p><\/li><\/ul>\n<h2>\u00a0<\/h2> <h2 style=\"text-align: center;\">Contact details<\/h2>\n<h3>Our details<\/h3> <p>Bank details<br \/>Fio Bank (Euro account)<br \/>Iban: CZ0920100000002401533202<br \/>BIC\/SWIFT: FIOBCZPPXXX<\/p> <p>\u00a0<\/p> <p>\u00a0<\/p> <p>\u00a0<\/p>\n\n<em><svg aria-hidden=\"true\"><use href=\"#tf-far-envelope\"><\/use><\/svg><\/em> info@angelsfriend.com <em><svg aria-hidden=\"true\"><use href=\"#tf-fas-phone\"><\/use><\/svg><\/em> +4420 3950 9372 <em><svg aria-hidden=\"true\"><use href=\"#tf-fas-mobile\"><\/use><\/svg><\/em> +420 777 159 622 (WhatsApp & Viber) <em><svg aria-hidden=\"true\"><use href=\"#tf-fas-mobile\"><\/use><\/svg><\/em> Skype: Angels Friend Surrogacy\n<h4><strong>Meeting address<\/strong><\/h4>\n<p>Pobrezni 249\/46<br \/>Prague 8, 18600<br \/>Czech Republic<\/p>\n\n<h4><strong>Registered address<\/strong><\/h4>\n<p>Dopravni 500\/9<br \/>Prague 10, 10400<br \/>Czech Republic<\/p>\n\n","_links":{"self":[{"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/pages\/426","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/comments?post=426"}],"version-history":[{"count":26,"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/pages\/426\/revisions"}],"predecessor-version":[{"id":2553,"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/pages\/426\/revisions\/2553"}],"wp:attachment":[{"href":"https:\/\/www.angelsfriend.com\/fr\/wp-json\/wp\/v2\/media?parent=426"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}