{"id":2529,"date":"2025-10-04T13:09:22","date_gmt":"2025-10-04T13:09:22","guid":{"rendered":"https:\/\/dryasserrifay.com\/?page_id=2529"},"modified":"2025-10-06T14:48:19","modified_gmt":"2025-10-06T14:48:19","slug":"fiche-patient","status":"publish","type":"page","link":"https:\/\/dryasserrifay.com\/en\/fiche-patient\/","title":{"rendered":"Fiche patient"},"content":{"rendered":"<style>.elementor-2529 .elementor-element.elementor-element-140e6745{--display:flex;--flex-direction:column;--container-widget-width:calc( ( 1 - var( --container-widget-flex-grow ) ) * 100% );--container-widget-height:initial;--container-widget-flex-grow:0;--container-widget-align-self:initial;--flex-wrap-mobile:wrap;--align-items:stretch;--gap:20px 20px;--row-gap:20px;--column-gap:20px;--overlay-opacity:0.89;--margin-top:0%;--margin-bottom:0%;--margin-left:0%;--margin-right:0%;--padding-top:20px;--padding-bottom:30px;--padding-left:20px;--padding-right:20px;overflow:visible;}.elementor-2529 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.elementor-heading-title{font-size:48px;line-height:1em;}.elementor-2529 .elementor-element.elementor-element-2adc9a55{padding:0px 0px 0px 0px;}.elementor-2529 .elementor-element.elementor-element-209bee81{margin:0px 0px calc(var(--kit-widget-spacing, 0px) + 0px) 0px;padding:0px 15px 30px 15px;}}\/* Start custom CSS for form, class: .elementor-element-209bee81 *\/.elementor-2529 .elementor-element.elementor-element-209bee81 input,\n.elementor-2529 .elementor-element.elementor-element-209bee81 textarea {\n    padding-left: 20px;  \/* Adjust the value as needed *\/\n}\/* End custom CSS *\/<\/style>\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2529\" class=\"elementor elementor-2529\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-140e6745 e-flex e-con-boxed e-con e-parent\" data-id=\"140e6745\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;ekit_has_onepagescroll_dot&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2a6fe0d3 elementor-widget elementor-widget-heading\" data-id=\"2a6fe0d3\" data-element_type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Referral Form \u2013 Patient Source<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2adc9a55 elementor-widget elementor-widget-text-editor\" data-id=\"2adc9a55\" data-element_type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p class=\"p1\">This form helps us understand how you found our clinic and allows us to better organize your follow-up care.<\/p><p 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data-form-id=\"209bee81\">{&quot;field_a5c9257&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_dd31fdd&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Autre&quot;,&quot;_id&quot;:&quot;76a6b91&quot;}]},&quot;field_ee76d59&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_fbcc59d&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Autres&quot;,&quot;_id&quot;:&quot;76a6b91&quot;}]},&quot;field_8c197db&quot;:{&quot;display_mode&quot;:&quot;show&quot;,&quot;fire_action&quot;:&quot;All&quot;,&quot;file_types&quot;:&quot;png&quot;,&quot;logic_data&quot;:[{&quot;cfef_logic_field_id&quot;:&quot;field_0808a07&quot;,&quot;cfef_logic_field_is&quot;:&quot;==&quot;,&quot;cfef_logic_compare_value&quot;:&quot;Autre&quot;,&quot;_id&quot;:&quot;76a6b91&quot;}]}}<\/template>\t\t<form class=\"elementor-form\" method=\"post\" name=\"Fiche de R\u00e9f\u00e9rence - Patient Infos\" aria-label=\"Fiche de R\u00e9f\u00e9rence - Patient Infos\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"2529\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"209bee81\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Fiche patient - DR Yasser Rifay\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"2529\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Name: \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_7aefad1 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7aefad1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tE-mail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_7aefad1]\" id=\"form-field-field_7aefad1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_511b8e4 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_511b8e4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSocial Media Profile:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_511b8e4]\" id=\"form-field-field_511b8e4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_dd31fdd elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dd31fdd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t1\/ Referred by:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ophtalmologiste\" id=\"form-field-field_dd31fdd-0\" name=\"form_fields[field_dd31fdd]\"> <label for=\"form-field-field_dd31fdd-0\">Ophthalmologist<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"M\u00e9decin non ophtalmologiste\" id=\"form-field-field_dd31fdd-1\" name=\"form_fields[field_dd31fdd]\"> <label for=\"form-field-field_dd31fdd-1\">Non-Ophthalmologist Doctor<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Opticien\" id=\"form-field-field_dd31fdd-2\" name=\"form_fields[field_dd31fdd]\"> <label for=\"form-field-field_dd31fdd-2\">Optician<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Orthoptiste\" id=\"form-field-field_dd31fdd-3\" name=\"form_fields[field_dd31fdd]\"> <label for=\"form-field-field_dd31fdd-3\">Orthoptist<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Oculariste\" id=\"form-field-field_dd31fdd-4\" name=\"form_fields[field_dd31fdd]\"> <label for=\"form-field-field_dd31fdd-4\">Ocularist<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Pharmacien\" id=\"form-field-field_dd31fdd-5\" name=\"form_fields[field_dd31fdd]\"> <label for=\"form-field-field_dd31fdd-5\">Pharmacist<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Autre\" id=\"form-field-field_dd31fdd-6\" name=\"form_fields[field_dd31fdd]\"> <label for=\"form-field-field_dd31fdd-6\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a5c9257 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a5c9257]\" id=\"form-field-field_a5c9257\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Please Specify\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_cdb580f elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cdb580f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2\/ Word of Mouth:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Oui\" id=\"form-field-field_cdb580f-0\" name=\"form_fields[field_cdb580f]\"> <label for=\"form-field-field_cdb580f-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Non\" id=\"form-field-field_cdb580f-1\" name=\"form_fields[field_cdb580f]\"> <label for=\"form-field-field_cdb580f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8ea58e6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8ea58e6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t \u2192 If yes, please specify the person:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8ea58e6]\" id=\"form-field-field_8ea58e6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_fbcc59d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fbcc59d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3\/ Social Media:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Instagram\" id=\"form-field-field_fbcc59d-0\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-0\">Instagram<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Facebook\" id=\"form-field-field_fbcc59d-1\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-1\">Facebook<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"TikTok\" id=\"form-field-field_fbcc59d-2\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-2\">TikTok<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Threads\" id=\"form-field-field_fbcc59d-3\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-3\">Threads<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"YouTube (vid\u00e9o explicative \/ short)\" id=\"form-field-field_fbcc59d-4\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-4\">YouTube (Informative Video \/ Short)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Story Whatsapp\" id=\"form-field-field_fbcc59d-5\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-5\">Story Whatsapp<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Groupe Facebook (\u00ab J\u2019ai test\u00e9\u2026 \u00bb)\" id=\"form-field-field_fbcc59d-6\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-6\">Facebook Group (\u201cI Tried\u2026\u201d)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Autres\" id=\"form-field-field_fbcc59d-7\" name=\"form_fields[field_fbcc59d]\"> <label for=\"form-field-field_fbcc59d-7\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ee76d59 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ee76d59]\" id=\"form-field-field_ee76d59\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Please Specify\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_0808a07 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0808a07\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t4\/ Type of Interaction:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Commentaire\" id=\"form-field-field_0808a07-0\" name=\"form_fields[field_0808a07]\"> <label for=\"form-field-field_0808a07-0\">Comments<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Inbox \/ Message priv\u00e9\" id=\"form-field-field_0808a07-1\" name=\"form_fields[field_0808a07]\"> <label for=\"form-field-field_0808a07-1\">Inbox \/ Private Message<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Story vue \/ partag\u00e9e\" id=\"form-field-field_0808a07-2\" name=\"form_fields[field_0808a07]\"> <label for=\"form-field-field_0808a07-2\">Story Viewed \/ Shared<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Vid\u00e9o explicative regard\u00e9e\" id=\"form-field-field_0808a07-3\" name=\"form_fields[field_0808a07]\"> <label for=\"form-field-field_0808a07-3\">Informative Video Watched<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Autre\" id=\"form-field-field_0808a07-4\" name=\"form_fields[field_0808a07]\"> <label for=\"form-field-field_0808a07-4\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8c197db elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8c197db]\" id=\"form-field-field_8c197db\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Please Specify\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"jki jki-send-line\"><\/i>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send <\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Fiche de R\u00e9f\u00e9rence \u2013 Origine du Patient Cette fiche nous aide \u00e0 savoir comment vous avez d\u00e9couvert le cabinet et \u00e0 mieux organiser votre suivi. Toutes vos r\u00e9ponses seront trait\u00e9es de mani\u00e8re confidentielle.<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-2529","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/pages\/2529","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/comments?post=2529"}],"version-history":[{"count":58,"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/pages\/2529\/revisions"}],"predecessor-version":[{"id":3065,"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/pages\/2529\/revisions\/3065"}],"wp:attachment":[{"href":"https:\/\/dryasserrifay.com\/en\/wp-json\/wp\/v2\/media?parent=2529"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}