{"id":9589,"date":"2023-02-14T14:03:37","date_gmt":"2023-02-14T19:03:37","guid":{"rendered":"https:\/\/www.feramax.com\/formulaire-de-contact-page-du-praticien\/"},"modified":"2026-10-20T12:11:43","modified_gmt":"2026-10-20T17:11:43","slug":"formulaire-de-contact-page-du-praticien","status":"publish","type":"page","link":"https:\/\/mh-gut.wpsitestage.com\/fr\/ressources-page-de-version-dessai\/praticien-de-sante\/formulaire-de-contact-page-du-praticien\/","title":{"rendered":"Mod\u00e8le de formulaire d&rsquo;autorisation de diffusion - Professionnels"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9589\" class=\"elementor elementor-9589 elementor-1696\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-31ddcb6c e-flex e-con-boxed e-con e-parent\" data-id=\"31ddcb6c\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1a35d980 elementor-widget elementor-widget-heading\" data-id=\"1a35d980\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Mod\u00e8le de formulaire d'autorisation de diffusion<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3384e97 elementor-widget elementor-widget-text-editor\" data-id=\"3384e97\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tCe formulaire est r\u00e9serv\u00e9 aux professionnels de sant\u00e9.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-5fac149 e-flex e-con-boxed e-con e-parent\" data-id=\"5fac149\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-73f8a1b elementor-widget elementor-widget-metform\" data-id=\"73f8a1b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"metform.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div id=\"mf-response-props-id-1698\" data-previous-steps-style=\"\" data-editswitchopen=\"\" data-response_type=\"alert\" data-erroricon=\"fas fa-exclamation-triangle\" data-successicon=\"fas fa-check\" data-messageposition=\"top\" class=\"   mf-scroll-top-no\">\n\t\t<div class=\"formpicker_warper formpicker_warper_editable\" data-metform-formpicker-key=\"1698\" >\n\t\t\t\t\n\t\t\t<div class=\"mf-widget-container\">\n\t\t\t\t\r\n\t\t<div\r\n\t\t\tid=\"metform-wrap-73f8a1b-1698\"\r\n\t\t\tclass=\"mf-form-wrapper\"\r\n\t\t\tdata-form-id=\"1698\"\r\n\t\t\tdata-action=\"https:\/\/mh-gut.wpsitestage.com\/fr\/wp-json\/metform\/v1\/entries\/insert\/1698\"\r\n\t\t\tdata-wp-nonce=\"fb513d5d6a\"\r\n\t\t\tdata-form-nonce=\"923f44a0a1\"\r\n\t\t\tdata-quiz-summery = \"false\"\r\n\t\t\tdata-save-progress = \"false\"\r\n\t\t\tdata-form-type=\"general-form\"\r\n\t\t\tdata-payment-submit-before=\"0\"\r\n\t\t\t\t\t\t><\/div>\r\n\r\n\r\n\t\t<!----------------------------- \r\n\t\t\t* controls_data : find the the props passed indie of data attribute\r\n\t\t\t* props.SubmitResponseMarkup : contains the markup of error or success message\r\n\t\t\t* https:\/\/developer.mozilla.org\/en-US\/docs\/Web\/JavaScript\/Reference\/Template_literals\r\n\t\t--------------------------- -->\r\n\r\n\t\t\t\t<script type=\"text\/mf\" class=\"mf-template\">\r\n\t\t\tfunction controls_data (value){\r\n\t\t\t\tlet currentWrapper = \"mf-response-props-id-1698\";\r\n\t\t\t\tlet currentEl = document.getElementById(currentWrapper);\r\n\t\t\t\t\r\n\t\t\t\treturn currentEl ? currentEl.dataset[value] : false\r\n\t\t\t}\r\n\r\n\r\n\t\t\tlet is_edit_mode = '' ? true : false;\r\n\t\t\tlet message_position = controls_data('messageposition') || 'top';\r\n\r\n\t\t\t\r\n\t\t\tlet message_successIcon = controls_data('successicon') || '';\r\n\t\t\tlet message_errorIcon = controls_data('erroricon') || '';\r\n\t\t\tlet message_editSwitch = controls_data('editswitchopen') === 'yes' ? true : false;\r\n\t\t\tlet message_proClass = controls_data('editswitchopen') === 'yes' ? 'mf_pro_activated' : '';\r\n\t\t\t\r\n\t\t\tlet is_dummy_markup = is_edit_mode && message_editSwitch ? true : false;\r\n\r\n\t\t\t\r\n\t\t\treturn html`\r\n\t\t\t\t<form\r\n\t\t\t\t\tclassName=\"metform-form-content\"\r\n\t\t\t\t\tref=${parent.formContainerRef}\r\n\t\t\t\t\tonSubmit=${ validation.handleSubmit( parent.handleFormSubmit ) }\r\n\t\t\t\t\r\n\t\t\t\t\t>\r\n\t\t\t\r\n\t\t\t\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'top' ?  props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? 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.mf-btn-wraper{text-align:center;}.elementor-1698 .elementor-element.elementor-element-273d553e .metform-btn{padding:25px 121px 25px 120px;font-family:\"Montserrat\", Sans-serif;font-size:16px;font-weight:700;text-transform:uppercase;line-height:11px;color:#FFFFFF;border-style:none;border-radius:36px 36px 36px 36px;}.elementor-1698 .elementor-element.elementor-element-273d553e .metform-btn:focus{color:#FFFFFF;}.elementor-1698 .elementor-element.elementor-element-273d553e .mf-btn-wraper svg{fill:#FFFFFF;}.elementor-1698 .elementor-element.elementor-element-273d553e .mf-btn-wraper i{color:#FFFFFF;}.elementor-1698 .elementor-element.elementor-element-273d553e .metform-btn:hover svg{fill:#FFFFFF;}.elementor-1698 .elementor-element.elementor-element-273d553e .metform-btn:hover i{color:#FFFFFF;}.elementor-1698 .elementor-element.elementor-element-273d553e .mf-btn-wraper svg {width:15px;}.elementor-1698 .elementor-element.elementor-element-273d553e .mf-btn-wraper i {font-size:15px;}.elementor-1698 .elementor-element.elementor-element-273d553e > .elementor-widget-container{margin:0px 0px 0px 0px;border-radius:8px 8px 8px 8px;}.elementor-1698 .elementor-element.elementor-element-273d553e{width:auto;max-width:auto;}.elementor-1698 .elementor-element.elementor-element-273d553e:hover .elementor-widget-container{box-shadow:0px 2px 4px 0px rgba(2.9999999999999996, 28.00000000000002, 90, 0.4);}.elementor-1698 .elementor-element.elementor-element-34bd394 > .elementor-widget-wrap > .elementor-widget:not(.elementor-widget__width-auto):not(.elementor-widget__width-initial):not(:last-child):not(.elementor-absolute){margin-block-end:0px;}.elementor-1698 .elementor-element.elementor-element-34bd394 > .elementor-element-populated{padding:13px 15px 11px 15px;}.elementor-1698 .elementor-element.elementor-element-701f37a > .elementor-widget-wrap > .elementor-widget:not(.elementor-widget__width-auto):not(.elementor-widget__width-initial):not(:last-child):not(.elementor-absolute){margin-block-end:0px;}.elementor-1698 .elementor-element.elementor-element-701f37a > .elementor-element-populated{padding:13px 15px 11px 15px;}.elementor-1698 .elementor-element.elementor-element-06b1622 > .elementor-widget-wrap > .elementor-widget:not(.elementor-widget__width-auto):not(.elementor-widget__width-initial):not(:last-child):not(.elementor-absolute){margin-block-end:0px;}.elementor-1698 .elementor-element.elementor-element-06b1622 > .elementor-element-populated{padding:13px 15px 11px 15px;}@media(max-width:1024px){.elementor-1698 .elementor-element.elementor-element-6dd41487{padding:35px 15px 35px 15px;}.elementor-1698 .elementor-element.elementor-element-273d553e .metform-btn{padding:25px 25px 25px 25px;}}@media(max-width:767px){.elementor-1698 .elementor-element.elementor-element-273d553e .mf-btn-wraper{text-align:center;}.elementor-1698 .elementor-element.elementor-element-273d553e .metform-btn{padding:20px 20px 20px 20px;}}@media(min-width:768px){.elementor-1698 .elementor-element.elementor-element-5568a318{width:69.765%;}.elementor-1698 .elementor-element.elementor-element-079631e{width:30.126%;}.elementor-1698 .elementor-element.elementor-element-5f655a7a{width:29.645%;}.elementor-1698 .elementor-element.elementor-element-34bd394{width:20.355%;}}<\/style>\t\t<div data-elementor-type=\"wp-post\" key=\"2\" data-elementor-id=\"1698\" className=\"elementor elementor-1698\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"metform-form\">\n\t\t\t\t\t\t<section className=\"elementor-section elementor-top-section elementor-element elementor-element-6dd41487 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"6dd41487\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-58630625\" data-id=\"58630625\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-39b5cb02 elementor-widget elementor-widget-heading\" data-id=\"39b5cb02\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t<h3 className=\"elementor-heading-title elementor-size-default\">Practitioner Form<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-54dbf2b elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"54dbf2b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-3f4ea38e\" data-id=\"3f4ea38e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-3a0f3a32 elementor-widget elementor-widget-mf-text\" data-id=\"3a0f3a32\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;clinic-practice-address&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-3a0f3a32\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Clinic\/Practice Name:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-3a0f3a32\"\r\n\t\t\t\tname=\"clinic-practice-address\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['clinic-practice-address'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"clinic-practice-address\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-0b51863 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"0b51863\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-6938d87\" data-id=\"6938d87\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-2392ed4 elementor-widget elementor-widget-mf-text\" data-id=\"2392ed4\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-last-name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-2392ed4\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Clinic\/Practice Address:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-2392ed4\"\r\n\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['mf-last-name'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"mf-last-name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-7df7c2d\" data-id=\"7df7c2d\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-dba5304 elementor-widget elementor-widget-mf-text\" data-id=\"dba5304\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;apt-suite&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-dba5304\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Apt\/Suite:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-dba5304\"\r\n\t\t\t\tname=\"apt-suite\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['apt-suite'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"Ce champ est n\\u00e9cessaire.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":false,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"apt-suite\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-f659fe2 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"f659fe2\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-3f7e957\" data-id=\"3f7e957\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-544b4f3 elementor-widget elementor-widget-mf-text\" data-id=\"544b4f3\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;City&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-544b4f3\">\r\n\t\t\t\t\t${ parent.decodeEntities(`City:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-544b4f3\"\r\n\t\t\t\tname=\"City\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['City'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"City\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-eb881d0\" data-id=\"eb881d0\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-9b6ac44 elementor-widget elementor-widget-mf-text\" data-id=\"9b6ac44\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Province&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-9b6ac44\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Province:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-9b6ac44\"\r\n\t\t\t\tname=\"Province\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['Province'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Province\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-c3ef3e3\" data-id=\"c3ef3e3\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-fc3a4b6 elementor-widget elementor-widget-mf-text\" data-id=\"fc3a4b6\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Post_Code_&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-fc3a4b6\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Postal Code:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-fc3a4b6\"\r\n\t\t\t\tname=\"Post_Code_\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['Post_Code_'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Post_Code_\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-bb5c3fb elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"bb5c3fb\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-9c52dc6\" data-id=\"9c52dc6\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-9e38a77 elementor-widget elementor-widget-mf-text\" data-id=\"9e38a77\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;Contact-Name&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-9e38a77\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Contact Name`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-9e38a77\"\r\n\t\t\t\tname=\"Contact-Name\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['Contact-Name'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"Contact-Name\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-b740016\" data-id=\"b740016\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-41b6ed3 elementor-widget elementor-widget-mf-email\" data-id=\"41b6ed3\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-email&quot;}\" data-widget_type=\"mf-email.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-email-41b6ed3\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Email Address`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input \r\n\t\t\t\ttype=\"email\" \r\n\t\t\t\t \r\n\t\t\t\tdefaultValue=\"\" \r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\" \r\n\t\t\t\tid=\"mf-input-email-41b6ed3\" \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t \r\n\t\t\t\tonBlur=${parent.handleChange} onFocus=${parent.handleChange} aria-invalid=\"${validation.errors['mf-email'] ? 'true' : 'false' }\" \r\n\t\t\t\tref=${el=> parent.activateValidation({\"message\":\"This field is required.\",\"emailMessage\":\"Veuillez saisir une adresse de messagerie valide\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\r\n\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t<${validation.ErrorMessage} \r\n\t\t\t\terrors=${validation.errors} \r\n\t\t\t\tname=\"mf-email\" \r\n\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-d9ae722\" data-id=\"d9ae722\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-f08b6e4 elementor-widget elementor-widget-mf-telephone\" data-id=\"f08b6e4\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-phone&quot;}\" data-widget_type=\"mf-telephone.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div className=\"mf-input-wrapper\">\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-telephone-f08b6e4\">\n\t\t\t\t\t${ parent.decodeEntities(`Phone Number:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\n\t\t\t\t<\/label>\n\t\t\t\n\t\t\t<input\n\t\t\t\ttype=\"tel\"\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\n\t\t\t\tid=\"mf-input-telephone-f08b6e4\" \n\t\t\t\tname=\"mf-phone\"\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\n\t\t\t\t\taria-invalid=\"${validation.errors['mf-phone'] ? 'true' : 'false'}\"\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\n\t\t\t\t\t\t\t\t\/>\n\t\t\t\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\n\t\t\t\t\terrors=${validation.errors}\n\t\t\t\t\tname=\"mf-phone\"\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\n\t\t\t\t\t\/>\n\t\t\t\n\t\t\t\n\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-77068073 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"77068073\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-2838a5b1\" data-id=\"2838a5b1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-76b282a elementor-widget elementor-widget-mf-telephone\" data-id=\"76b282a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-Fax&quot;}\" data-widget_type=\"mf-telephone.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div className=\"mf-input-wrapper\">\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-telephone-76b282a\">\n\t\t\t\t\t${ parent.decodeEntities(`Fax Number:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\n\t\t\t\t<\/label>\n\t\t\t\n\t\t\t<input\n\t\t\t\ttype=\"tel\"\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\n\t\t\t\tid=\"mf-input-telephone-76b282a\" \n\t\t\t\tname=\"mf-Fax\"\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\n\t\t\t\t\taria-invalid=\"${validation.errors['mf-Fax'] ? 'true' : 'false'}\"\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\n\t\t\t\t\t\t\t\t\/>\n\t\t\t\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\n\t\t\t\t\terrors=${validation.errors}\n\t\t\t\t\tname=\"mf-Fax\"\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\n\t\t\t\t\t\/>\n\t\t\t\n\t\t\t\n\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-7de875e7\" data-id=\"7de875e7\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-528a3b0 elementor-widget elementor-widget-mf-telephone\" data-id=\"528a3b0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;number-of-Practitioners&quot;}\" data-widget_type=\"mf-telephone.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div className=\"mf-input-wrapper\">\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-telephone-528a3b0\">\n\t\t\t\t\t${ parent.decodeEntities(`Number of Practitioners:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\n\t\t\t\t<\/label>\n\t\t\t\n\t\t\t<input\n\t\t\t\ttype=\"tel\"\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\n\t\t\t\tid=\"mf-input-telephone-528a3b0\" \n\t\t\t\tname=\"number-of-Practitioners\"\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\n\t\t\t\t\taria-invalid=\"${validation.errors['number-of-Practitioners'] ? 'true' : 'false'}\"\n\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)}\n\t\t\t\t\t\t\t\t\/>\n\t\t\t\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\n\t\t\t\t\terrors=${validation.errors}\n\t\t\t\t\tname=\"number-of-Practitioners\"\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\n\t\t\t\t\t\/>\n\t\t\t\n\t\t\t\n\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-b7e1c0a elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"b7e1c0a\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-35fb151\" data-id=\"35fb151\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-c841729 elementor-widget elementor-widget-mf-text\" data-id=\"c841729\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;practice-needs&quot;}\" data-widget_type=\"mf-text.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\r\n\t\t<div className=\"mf-input-wrapper\">\r\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-text-c841729\">\r\n\t\t\t\t\t${ parent.decodeEntities(`Tell us about your Practice needs:`) } \t\t\t\t\t<span className=\"mf-input-required-indicator\">*<\/span>\r\n\t\t\t\t<\/label>\r\n\t\t\t\r\n\t\t\t<input\r\n\t\t\t\ttype=\"text\"\r\n\t\t\t\tclassName=\"mf-input mf-conditional-input\"\r\n\t\t\t\tid=\"mf-input-text-c841729\"\r\n\t\t\t\tname=\"practice-needs\"\r\n\t\t\t\tplaceholder=\"${ parent.decodeEntities(``) } \"\r\n\t\t\t\t\t\t\t\t\tonInput=${parent.handleChange}\r\n\t\t\t\t\tonBlur=${parent.handleChange}\r\n\t\t\t\t\taria-invalid=\"${validation.errors['practice-needs'] ? 'true' : 'false'}\"\r\n\t\t\t\t\tref=${el =>{\r\n\t\t\t\t\t\t\t\t\t\t\t\tparent.activateValidation({\"message\":\"This field is required.\",\"minLength\":1,\"maxLength\":\"\",\"type\":\"none\",\"required\":true,\"expression\":\"null\"}, el)\r\n\t\t\t\t\t}}\r\n\t\t\t\t\t\t\t\t\/>\r\n\r\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\r\n\t\t\t\t\terrors=${validation.errors}\r\n\t\t\t\t\tname=\"practice-needs\"\r\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\r\n\t\t\t\t\t\/>\r\n\t\t\t\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-321ad043 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"321ad043\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-5568a318\" data-id=\"5568a318\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-dde444b elementor-widget elementor-widget-mf-listing-optin\" data-id=\"dde444b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;mf_input_name&quot;:&quot;mf-listing-optin&quot;}\" data-widget_type=\"mf-listing-optin.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\n\t\t<div className=\"mf-input-wrapper\">\n\t\t\t\t\t\t\t<label className=\"mf-input-label\" htmlFor=\"mf-input-optin-dde444b\">\n\t\t\t\t\t${ parent.decodeEntities(``) } \t\t\t\t\t<span className=\"mf-input-required-indicator\"><\/span>\n\t\t\t\t<\/label>\n\t\t\t\n\t\t\t<div className=\"mf-checkbox multi-option-input-type\" id=\"mf-input-optin-dde444b\">\n\t\t\t\t<div className=\"mf-checkbox-option\">\n\t\t\t\t\t<label>\n\t\t\t\t\t\t\t\t\t\t\t\t<input\n\t\t\t\t\t\t\ttype=\"checkbox\"\n\t\t\t\t\t\t\tclassName=\"mf-input mf-checkbox-input \"\n\t\t\t\t\t\t\tname=\"mf-listing-optin\" \n\t\t\t\t\t\t\tvalue=\"1\"\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tonInput=${ parent.handleOptin }\n\t\t\t\t\t\t\t\taria-invalid=\"${validation.errors['mf-listing-optin'] ? 'true' : 'false'}\"\n\t\t\t\t\t\t\t\tref=${el => parent.activateValidation({\"message\":\"Ce champ est n\\u00e9cessaire.\",\"required\":false}, el)}\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/>\n\t\t\t\t\t\t<span>\n\t\t\t\t\t\t\tI agree to allow BioSyent to contact me by email regarding the FeraMAX\u00aePd\u00a0Sample Program. I may withdraw my consent at any time through the unsubscribe link. See our <a href=\"https:\/\/mh-gut.wpsitestage.com\/privacy-policy\/\">Privacy Policy<\/a> for more details on how we protect your personal information.\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<${validation.ErrorMessage}\n\t\t\t\t\terrors=${validation.errors}\n\t\t\t\t\tname=\"mf-listing-optin\"\n\t\t\t\t\tas=${html`<span className=\"mf-error-message\"><\/span>`}\n\t\t\t\t\t\/>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-079631e\" data-id=\"079631e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section className=\"elementor-section elementor-inner-section elementor-element elementor-element-33368ce5 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"33368ce5\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div className=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-5f655a7a\" data-id=\"5f655a7a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div className=\"elementor-element elementor-element-273d553e elementor-widget__width-auto mf-btn--mobile-center mf-btn--center elementor-widget elementor-widget-mf-button\" data-id=\"273d553e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"mf-button.default\">\n\t\t\t\t<div className=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div className=\"mf-btn-wraper mf-conditional-input\" data-mf-form-conditional-logic-requirement=\"\">\r\n\t\t\t\t\t\t\t<button type=\"submit\" className=\"metform-btn metform-submit-btn \" id=\"\">\r\n\t\t\t\t\t<span>${ parent.decodeEntities(`SUBMIT`) } <\/span>\r\n\t\t\t\t\t<i aria-hidden=\"true\" className=\"hm hm-arrow-right\"><\/i>\t\t\t\t<\/button>\r\n\t\t\t        <\/div>\r\n        \t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-34bd394\" data-id=\"34bd394\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-701f37a\" data-id=\"701f37a\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div className=\"elementor-column elementor-col-25 elementor-inner-column elementor-element elementor-element-06b1622\" data-id=\"06b1622\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div className=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t`}\r\n\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t${is_dummy_markup ? message_position === 'bottom' ? props.ResponseDummyMarkup(message_successIcon, message_proClass) : '' : ''}\r\n\t\t\t\t\t${is_dummy_markup ? 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