{"id":659789,"date":"2026-06-17T10:23:45","date_gmt":"2026-06-17T15:23:45","guid":{"rendered":"https:\/\/espacedentairemd.plogg.dev\/?page_id=659789"},"modified":"2026-06-17T10:24:03","modified_gmt":"2026-06-17T15:24:03","slug":"formulaire-consentement-mineur","status":"publish","type":"page","link":"https:\/\/espacedentairemd.plogg.dev\/en\/formulaire-consentement-mineur\/","title":{"rendered":"Minor Consent Form"},"content":{"rendered":"\n    <div id=\"wp-plogg-consent-div\" class=\"consent-form-shortcode canvas_div_pdf\">\n\n        <div class=\"page-loader\"><\/div>\n\n         \n\n        <form action=\"https:\/\/espacedentairemd.plogg.dev\/wp-content\/plugins\/wp-plogg-consent\/includes\/form-manager.php\" onsubmit=\"return wp_plogg_consent_validation_en()\" method=\"post\" id=\"consent-contact-form\" enctype=\"multipart\/form-data\">\n\n            <input type=\"hidden\" name=\"wp_plogg_consent_lang\" id=\"wp_plogg_consent_lang\" value=\"en\" \/>\n            <input type=\"hidden\" name=\"wp_plogg_consent_attr_lang\" id=\"wp_plogg_consent_attr_lang\" value=\"fr\" \/>\n            <input type=\"hidden\" name=\"wp_plogg_consent_attr_second_text\" id=\"wp_plogg_consent_attr_second_text\" value=\"1\" \/>\n            <input type=\"hidden\" name=\"wp_plogg_consent_nomformulaire\" id=\"wp_plogg_consent_nomformulaire\" value=\"consent\" \/>\n            <input type=\"hidden\" name=\"wp_plogg_consent_goto\" id=\"wp_plogg_consent_goto\" value=\"https:\/\/espacedentairemd.plogg.dev\/en\/formulaire-consentement-mineur\/\" \/>\n            <input type=\"text\" name=\"wp_plogg_consent_magicfield\"  class=\"wp_plogg_consent_magicfield\" value=\"\" autocomplete=\"off\"\/>\n\n            <h2>Consent Form for the Collection and Use of a Minor's Personal Information<\/h2>\r\nI, the undersigned, <input type=\"text\" class=\"input_text_style\" name=\"name_sign_3\" id=\"name_sign_3\" placeholder=\"First and last name\" \/>, hereby give my consent to the collection, use, and disclosure of the personal information of the minor, <input type=\"text\" class=\"input_text_style\" name=\"name_sign_4\" id=\"name_sign_4\" placeholder=\"First and last name\" \/>,\r\n\r\nof whom I am the legal guardian, by ESPACE DENTAIRE MD for the purpose of providing them with dental services.\r\n\r\nI acknowledge having received information on how their personal information will be collected, used, shared, stored, and protected.\r\n\r\nI acknowledge having received information on their rights regarding their personal information.\r\nThe above information can be found in ESPACE DENTAIRE MD's Privacy Policy.\r\n\r\nI understand that consent is valid as long as the minor is a patient of ESPACE DENTAIRE MD and that I can withdraw consent to the collection and use of <strong><span class=\"span_name_sign_2\">_________________<\/span><\/strong>'s personal information\r\n\r\nat any time, according to the procedure described in ESPACE DENTAIRE MD's privacy policy. However, this may prevent ESPACE DENTAIRE MD from providing them with dental services.\r\n\r\nI have read and understood the above information and voluntarily consent to the collection and use of personal information as described.\r\n\r\n<div class=\"signatureInner\"><p><strong>Signature<\/strong><\/p><div class=\"sigPadConsentement\" id=\"sigPadConsentement_1\"><div class=\"sig sigWrapper\"><div class=\"typed\"><\/div><canvas class=\"pad\" width=\"250\" height=\"100\"><\/canvas><input type=\"hidden\" name=\"signature_consentement\" id=\"signature_consentement\" value=\"\" class=\"output\"><\/div><div class=\"error-signature-consentement\"><\/div><div class=\"clearButton\" style=\"margin-top: 10px;\"><a href=\"#clear\">Delete signature<\/a><\/div><\/div><\/div>\r\n\r\n<strong>Date:<\/strong><input class=\"input_text_style datepicker consentdate\" id=\"date_1\" name=\"date_1\" inputmode=\"none\" type=\"text\" autocomplete=\"off\" placeholder=\"DD MM YYYY\">            \n            <br>            \n                      \n\n                            <button type=\"submit\" class=\"button wp-plogg-consent-form-button\" name=\"submit\">Send<\/button>\n            \n        <\/form>\n    <\/div>\n\n    \n    <script type=\"text\/javascript\">\n\n        jQuery(document).ready(function(){\n\n            if (jQuery(document).find('#sigPadConsentement_1')) {\n                var sigPadConsentement_1 = jQuery(document).find('#sigPadConsentement_1').signaturePad({drawOnly:true,lineWidth: 0, validateFields:true, errorMessageDraw:jQuery('.error-signature-consentement').text()});\n            }\n\n            if (jQuery(document).find('#sigPadConsentement_2')) {\n                var sigPadConsentement_2 = jQuery(document).find('#sigPadConsentement_2').signaturePad({drawOnly:true,lineWidth: 0, validateFields:true, errorMessageDraw:jQuery('.error-signature-consentement').text()});\n            }\n                \n            if (jQuery(document).find('#name_sign_gender_1')) {\n\n                jQuery('#name_sign_gender_1').on('change', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"____\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_gender_1').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#name_sign_1')) {\n\n                jQuery('#name_sign_1').on('keyup', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"__________________\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_1').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#name_sign_gender_2')) {\n\n                jQuery('#name_sign_gender_2').on('change', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"____\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_gender_2').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#name_sign_2')) {\n\n                jQuery('#name_sign_2').on('keyup', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"__________________\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_2').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#name_sign_gender_3')) {\n\n                jQuery('#name_sign_gender_3').on('change', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"____\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_gender_3').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#name_sign_3')) {\n\n                jQuery('#name_sign_3').on('keyup', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"__________________\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_3').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#name_sign_gender_4')) {\n\n                jQuery('#name_sign_gender_4').on('change', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"____\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_gender_4').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#name_sign_4')) {\n\n                jQuery('#name_sign_4').on('keyup', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"__________________\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_name_sign_4').text(text_value);\n                });\n\n            }\n\n            if (jQuery(document).find('#date_1')) {\n\n                jQuery('#date_1').on('change', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"_________________\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_date_1').text(text_value);\n                }); \n\n            }\n\n            if (jQuery(document).find('#date_2')) {\n\n                jQuery('#date_2').on('change', function(){\n                    var text_value = '';\n\n                    if (jQuery(this).val() == '') {\n                        text_value = \"_________________\";\n                    } else {\n                        text_value = jQuery(this).val();                    \n                    }\n\n                    jQuery('.span_date_2').text(text_value);\n                }); \n\n            }           \n\n            setTimeout(function() { \n                jQuery('.consentpopnotification').remove();\n            }, 3000);\n\n        });\n\n    <\/script>\n\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"page-category":[],"class_list":["post-659789","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/pages\/659789","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/comments?post=659789"}],"version-history":[{"count":2,"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/pages\/659789\/revisions"}],"predecessor-version":[{"id":659791,"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/pages\/659789\/revisions\/659791"}],"wp:attachment":[{"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/media?parent=659789"}],"wp:term":[{"taxonomy":"page-category","embeddable":true,"href":"https:\/\/espacedentairemd.plogg.dev\/en\/wp-json\/wp\/v2\/page-category?post=659789"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}