{"id":659793,"date":"2026-06-17T10:25:22","date_gmt":"2026-06-17T15:25:22","guid":{"rendered":"https:\/\/espacedentairemd.plogg.dev\/?page_id=659793"},"modified":"2026-06-17T10:25:22","modified_gmt":"2026-06-17T15:25:22","slug":"adult-consent-form","status":"publish","type":"page","link":"https:\/\/espacedentairemd.plogg.dev\/en\/adult-consent-form\/","title":{"rendered":"Adult 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=\"0\" \/>\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\/adult-consent-form\/\" \/>\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 personal information<\/h2>\r\nI, <select class=\"input_text_style input_select\" name=\"name_sign_gender_1\" id=\"name_sign_gender_1\"><option value=\"\">Select<\/option><option value=\"Miss\">Miss<\/option><option value=\"Ms.\">Ms.<\/option><option value=\"Mr.\">Mr.<\/option><\/select> <input type=\"text\" class=\"input_text_style\" name=\"name_sign_1\" id=\"name_sign_1\" placeholder=\"First and last name\" \/>, hereby give my consent to the collection, use and disclosure of my personal information by ESPACE DENTAIRE MD\u00a0for the purpose of providing me with dental services.\r\n\r\nI acknowledge that I have received information about how my personal information will be collected, used, shared, stored and protected.\r\n\r\nI acknowledge that I have received information about my rights regarding my personal information.\r\n\r\nThe preceding information can be found in the ESPACE DENTAIRE MD\u00a0privacy policy.\r\n\r\nI understand that consent is valid for as long as I am a patient of ESPACE DENTAIRE MD and that I may withdraw my consent to the collection and use of my personal information at any time in accordance with the procedure described in ESPACE DENTAIRE MD's Privacy Policy. However, this may prevent ESPACE DENTAIRE MD\u00a0from providing me with dental services.\r\n\r\nI have read and understood the above information and voluntarily consent to the collection and use of my 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><span class=\"span_name_sign_gender_1\">____<\/span> <span class=\"span_name_sign_1\">_________________<\/span><\/strong>\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(); 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