{"id":48626,"date":"2024-01-19T12:05:49","date_gmt":"2024-01-19T11:05:49","guid":{"rendered":"https:\/\/biorius.com\/rapport-devenement-indesirable-biorius\/rapport-sur-les-effets-indesirables-weareneen\/"},"modified":"2025-11-19T13:09:10","modified_gmt":"2025-11-19T12:09:10","slug":"rapport-sur-les-effets-indesirables-weareneen","status":"publish","type":"page","link":"https:\/\/biorius.com\/fr\/rapport-sur-les-effets-indesirables-weareneen\/","title":{"rendered":"Rapport sur les effets ind\u00e9sirables Weareneen"},"content":{"rendered":"\n<div data-elementor-type=\"wp-page\" data-elementor-id=\"48626\" class=\"elementor elementor-48626 elementor-46241\" data-elementor-post-type=\"page\">\n<div class=\"elementor-element elementor-element-88f8fd2 e-flex e-con-boxed e-con e-parent\" data-id=\"88f8fd2\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-06df1d7 elementor-widget elementor-widget-heading\" data-id=\"06df1d7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n<div class=\"elementor-widget-container\">\n<h1 class=\"elementor-heading-title elementor-size-default\">Adverse Event Report<\/h1>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-3a4f436 elementor-widget elementor-widget-html\" data-id=\"3a4f436\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n<div class=\"elementor-widget-container\">\n<div class=\"breadcrumbs\">\n<ul>\n<li>\n            <a href=\"https:\/\/biorius.com\/\">Home<\/a>\n        <\/li>\n<li>\n            <a href=\"#\">Adverse Event Report<\/a>\n        <\/li>\n<\/ul>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-4a556ba e-flex e-con-boxed e-con e-parent\" data-id=\"4a556ba\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-70d3b53 elementor-widget elementor-widget-image\" data-id=\"70d3b53\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"582\" height=\"243\" src=\"https:\/\/biorius.com\/wp-content\/uploads\/2024\/01\/Neen.webp\" class=\"attachment-large size-large wp-image-46243\" alt=\"\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-f703c99 e-con-full e-flex e-con e-child\" data-id=\"f703c99\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"elementor-element elementor-element-ba3f987 elementor-widget elementor-widget-heading\" data-id=\"ba3f987\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n<div class=\"elementor-widget-container\">\n<h1 class=\"elementor-heading-title elementor-size-default\">Cosmetic Product Safety<br \/>Reporting Health Issue:<\/h1>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-e1401f3 e-flex e-con-boxed e-con e-parent\" data-id=\"e1401f3\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-a0fdff0 e-con-full e-flex e-con e-child\" data-id=\"a0fdff0\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"elementor-element elementor-element-d9b4853 elementor-widget elementor-widget-text-editor\" data-id=\"d9b4853\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n<div class=\"elementor-widget-container\">\n<p><span style=\"color: #93d500;\"><strong>Your Well-being is Our Priority<\/strong><\/span><br \/>We understand your misfortune and we are sincerely sorry for you. We will investigate the case, but we need your help: please just fill in the form for the bad or unwanted reactions you encountered and submit it and you will be contacted by one of our experts. Thank you very much for your contribution and we hope you will get well soon.<\/p>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-697905b e-flex e-con-boxed e-con e-parent\" data-id=\"697905b\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-9824813 elementor-widget__width-inherit elementor-widget elementor-widget-gk_elementor_gravity_form\" data-id=\"9824813\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"gk_elementor_gravity_form.default\">\n<div class=\"elementor-widget-container\">\n<div class=\"gk-gravity-form\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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n\u00e9cessaires<\/p>\n<\/p><\/div>\n<form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/fr\/wp-json\/wp\/v2\/pages\/48626' data-formid='4' novalidate>\n<div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeU9SIqAAAAAFxZQ73mH3MP9-aJLNPkaprZhj7H' data-tabindex='0'><input id=\"input_35be03f21148cf7daf00d9edcddf7231\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_35be03f21148cf7daf00d9edcddf7231\" value=\"\"\/><\/div>\n<div class='gform-body gform_body'>\n<div id='gform_fields_4' class='gform_fields top_label form_sublabel_above description_below validation_below'>\n<div id=\"field_4_71\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--honeypot gfield--\"  data-field-class=\"gfield--honeypot gfield--\" ><label class='gfield_label gform-field-label' for='input_4_71'>Name<\/label><\/p>\n<div class='ginput_container'><input name='input_71' id='input_4_71' type='text' value='' autocomplete='new-password'\/><\/div>\n<div class='gfield_description' id='gfield_description_4_71'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div>\n<\/div>\n<fieldset id=\"field_4_69\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--consent gfield--large\"  data-field-class=\"gfield--consent gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_consent'><input name='input_69.1' id='input_4_69_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_69_1' >I agree to the processing of my personal data.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_69.2' value='I agree to the processing of my personal data.' class='gform_hidden' \/><input type='hidden' name='input_69.3' value='2' class='gform_hidden' \/><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_70\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--consent gfield--large\"  data-field-class=\"gfield--consent gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend>\n<div class='ginput_container ginput_container_consent'><input name='input_70.1' id='input_4_70_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_70_1' >I agree that this data may be shared with the distributor and\/or the cosmetic product brand and\/or authorities of my country.<\/label><input type='hidden' name='input_70.2' value='I agree that this data may be shared with the distributor and\/or the cosmetic product brand and\/or authorities of my country.' class='gform_hidden' \/><input type='hidden' name='input_70.3' value='2' class='gform_hidden' \/><\/div>\n<\/fieldset>\n<div id=\"field_4_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--medium\"  data-field-class=\"gfield--section gfield--medium\" >\n<h3 class=\"gsection_title\">A. Consumer Information<\/h3>\n<\/div>\n<fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_1'>\n<p>                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='false'    autocomplete=\"given-name\" \/><br \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_66\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_66'>\n<p>                            <span id='input_4_66_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_66.6' id='input_4_66_6' value=''   aria-required='false'    autocomplete=\"family-name\" \/><br \/>\n                                                    <label for='input_4_66_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<div id=\"field_4_61\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_61'>Date of Birth<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_4_61' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_61_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_61_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_61' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<fieldset id=\"field_4_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Sex<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_27'>\n<div class='gchoice gchoice_4_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Male'  id='choice_4_27_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_1' id='label_4_27_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Female'  id='choice_4_27_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_2' id='label_4_27_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Undifferentiated'  id='choice_4_27_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_3' id='label_4_27_3' class='gform-field-label gform-field-label--type-inline'>Undifferentiated<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Decline to answer'  id='choice_4_27_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_4' id='label_4_27_4' class='gform-field-label gform-field-label--type-inline'>Decline to answer<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_4_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Ethnicity<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_26'>\n<div class='gchoice gchoice_4_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='American Indian\/Alaska Native'  id='choice_4_26_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_1' id='label_4_26_1' class='gform-field-label gform-field-label--type-inline'>American Indian\/Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Black or African American'  id='choice_4_26_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_2' id='label_4_26_2' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Asian'  id='choice_4_26_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_3' id='label_4_26_3' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Native Hawaiian\/Other Pacific Islander'  id='choice_4_26_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_4' id='label_4_26_4' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian\/Other Pacific Islander<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='Hispanic\/Latino'  id='choice_4_26_5'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_5' id='label_4_26_5' class='gform-field-label gform-field-label--type-inline'>Hispanic\/Latino<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Caucasian'  id='choice_4_26_6'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_6' id='label_4_26_6' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_4_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Gender: Enter the patient\u2019s current gender (how the patient thinks of themself).<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_28'>\n<div class='gchoice gchoice_4_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Cisgender man\/boy (gender corresponds with birth sex)'  id='choice_4_28_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_1' id='label_4_28_1' class='gform-field-label gform-field-label--type-inline'>Cisgender man\/boy (gender corresponds with birth sex)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Cisgender woman\/girl (gender corresponds with birth sex)'  id='choice_4_28_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_2' id='label_4_28_2' class='gform-field-label gform-field-label--type-inline'>Cisgender woman\/girl (gender corresponds with birth sex)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Transgender man\/trans man\/ (female-to-male)'  id='choice_4_28_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_3' id='label_4_28_3' class='gform-field-label gform-field-label--type-inline'>Transgender man\/trans man\/ (female-to-male)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Transgender woman\/trans woman\/ (male-to-female)'  id='choice_4_28_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_4' id='label_4_28_4' class='gform-field-label gform-field-label--type-inline'>Transgender woman\/trans woman\/ (male-to-female)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Other gender category'  id='choice_4_28_5'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_5' id='label_4_28_5' class='gform-field-label gform-field-label--type-inline'>Other gender category<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='Decline to answer'  id='choice_4_28_6'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_6' id='label_4_28_6' class='gform-field-label gform-field-label--type-inline'>Decline to answer<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_4_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--large\"  data-field-class=\"gfield--section gfield--large\" >\n<h3 class=\"gsection_title\">B. Adverse Event or Product Problem<\/h3>\n<\/div>\n<fieldset id=\"field_4_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of Report (check all that apply)<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_30'>\n<div class='gchoice gchoice_4_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Product problem (e.g. defects\/malfunctions)'  id='choice_4_30_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_1' id='label_4_30_1' class='gform-field-label gform-field-label--type-inline'>Product problem (e.g. defects\/malfunctions)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Adverse event (e.g. allergy, irritation, \u2026)'  id='choice_4_30_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_2' id='label_4_30_2' class='gform-field-label gform-field-label--type-inline'>Adverse event (e.g. allergy, irritation, \u2026)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Serious adverse event (e.g. permanent damage, hospitalization, life-threatening, \u2026)'  id='choice_4_30_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_3' id='label_4_30_3' class='gform-field-label gform-field-label--type-inline'>Serious adverse event (e.g. permanent damage, hospitalization, life-threatening, \u2026)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_4_64\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_64'>Date of Event<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_64' id='input_4_64' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_64_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_64_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_64' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_4_62\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_62'>Date of this Report<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_62' id='input_4_62' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='04\/07\/2026' aria-describedby=\"input_4_62_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_62_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_62' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_4_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--textarea gfield--large\"  data-field-class=\"gfield--textarea gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_34'>Describe Event or Problem<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_4_34' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_4_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--textarea gfield--large\"  data-field-class=\"gfield--textarea gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_35'>Additional comments and other relevant history (e.g. allergies, pregnancy, tobacco product use, alcohol use, etc.)<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_4_35' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_4_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--large\"  data-field-class=\"gfield--section gfield--large\" >\n<h3 class=\"gsection_title\">C. Suspect Product<\/h3>\n<\/div>\n<div id=\"field_4_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_65'>Brand name<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_65' id='input_4_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_44'>Product Name<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_44' id='input_4_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_49'>Lot #<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_49' id='input_4_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_51'>Dose or Amount<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_51' id='input_4_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_52'>Frequency<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_63'>Expiration Date<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_63' id='input_4_63' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_4_63_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_63_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_63' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_4_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--large\"  data-field-class=\"gfield--section gfield--large\" >\n<h3 class=\"gsection_title\">D. Initial Reporter<\/h3>\n<\/div>\n<fieldset id=\"field_4_55\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden gfield--name gfield--large\"  data-field-class=\"gfield--name gfield--large\" >\n<div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div>\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_55'>\n<p>                            <span id='input_4_55_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <label for='input_4_55_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label><br \/>\n                                                    <input type='text' name='input_55.3' id='input_4_55_3' value=''   aria-required='true'     \/><br \/>\n                                                <\/span><\/p>\n<p>                            <span id='input_4_55_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                            <label for='input_4_55_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label><br \/>\n                                                            <input type='text' name='input_55.6' id='input_4_55_6' value=''   aria-required='true'     \/><br \/>\n                                                        <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_67\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_67'>\n<p>                            <span id='input_4_67_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_67.3' id='input_4_67_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/><br \/>\n                                                    <label for='input_4_67_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pr\u00e9nom<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_68\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_68'>\n<p>                            <span id='input_4_68_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_68.6' id='input_4_68_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/><br \/>\n                                                    <label for='input_4_68_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nom<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_54\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--address gfield--large\"  data-field-class=\"gfield--address gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>\n<div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_4_54' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_54_1_container' ><br \/>\n                                        <label for='input_4_54_1' id='input_4_54_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label><br \/>\n                                        <input type='text' name='input_54.1' id='input_4_54_1' value=''    aria-required='false'    \/><br \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_4_54_2_container' ><br \/>\n                                        <label for='input_4_54_2' id='input_4_54_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label><br \/>\n                                        <input type='text' name='input_54.2' id='input_4_54_2' value=''     aria-required='false'   \/><br \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_54_3_container' ><br \/>\n                                    <label for='input_4_54_3' id='input_4_54_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label><br \/>\n                                    <input type='text' name='input_54.3' id='input_4_54_3' value=''    aria-required='false'    \/><br \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_54_4_container' ><br \/>\n                                        <label for='input_4_54_4' id='input_4_54_4_label' class='gform-field-label gform-field-label--type-sub '>\u00c9tat \/ Province \/ R\u00e9gion<\/label><br \/>\n                                        <input type='text' name='input_54.4' id='input_4_54_4' value=''      aria-required='false'    \/><br \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_54_5_container' ><br \/>\n                                    <label for='input_4_54_5' id='input_4_54_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Code postal<\/label><br \/>\n                                    <input type='text' name='input_54.5' id='input_4_54_5' value=''    aria-required='false'    \/><br \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_4_54_6_container' ><br \/>\n                                        <label for='input_4_54_6' id='input_4_54_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label><br \/>\n                                        <select name='input_54.6' id='input_4_54_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Afrique du Sud' >Afrique du Sud<\/option><option value='Albanie' >Albanie<\/option><option value='Alg\u00e9rie' >Alg\u00e9rie<\/option><option value='Allemagne' >Allemagne<\/option><option value='Andorre' >Andorre<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctique' >Antarctique<\/option><option value='Antigua-et-Barbuda' >Antigua-et-Barbuda<\/option><option value='Arabie Saoudite' >Arabie Saoudite<\/option><option value='Argentine' >Argentine<\/option><option value='Arm\u00e9nie' >Arm\u00e9nie<\/option><option value='Aruba' >Aruba<\/option><option value='Australie' >Australie<\/option><option value='Autriche' >Autriche<\/option><option value='Azerba\u00efdjan' >Azerba\u00efdjan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahre\u00efn' >Bahre\u00efn<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Belarus' >Belarus<\/option><option value='Belgique' >Belgique<\/option><option value='Belize' >Belize<\/option><option value='Bermudes' >Bermudes<\/option><option value='Bhoutan' >Bhoutan<\/option><option value='Bolivie' >Bolivie<\/option><option value='Bonaire, Saint-Eustache et Saba ' >Bonaire, Saint-Eustache et Saba <\/option><option value='Bosnie-Herz\u00e9govine' >Bosnie-Herz\u00e9govine<\/option><option value='Botswana' >Botswana<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Br\u00e9sil' >Br\u00e9sil<\/option><option value='Bulgarie' >Bulgarie<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9nin' >B\u00e9nin<\/option><option value='Cambodge' >Cambodge<\/option><option value='Cameroun' >Cameroun<\/option><option value='Canada' >Canada<\/option><option value='Cap-Vert' >Cap-Vert<\/option><option value='Chili' >Chili<\/option><option value='Chine' >Chine<\/option><option value='Chypre' >Chypre<\/option><option value='Colombie' >Colombie<\/option><option value='Comores' >Comores<\/option><option value='Congo' >Congo<\/option><option value='Cor\u00e9e (R\u00e9publique de)' >Cor\u00e9e (R\u00e9publique de)<\/option><option value='Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)' >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatie' >Croatie<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='C\u00f4te d\u2019Ivoire' >C\u00f4te d\u2019Ivoire<\/option><option value='Danemark' >Danemark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominique' >Dominique<\/option><option value='Espagne' >Espagne<\/option><option value='Estonie' >Estonie<\/option><option value='Eswatini' >Eswatini<\/option><option value='Fidji' >Fidji<\/option><option value='Finlande' >Finlande<\/option><option value='France' >France<\/option><option value='F\u00e9d\u00e9ration Russe' >F\u00e9d\u00e9ration Russe<\/option><option value='Gabon' >Gabon<\/option><option value='Gambie' >Gambie<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Grenade' >Grenade<\/option><option value='Groenland' >Groenland<\/option><option value='Gr\u00e8ce' >Gr\u00e8ce<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guin\u00e9e' >Guin\u00e9e<\/option><option value='Guin\u00e9e \u00e9quatoriale' >Guin\u00e9e \u00e9quatoriale<\/option><option value='Guin\u00e9e-Bissau' >Guin\u00e9e-Bissau<\/option><option value='Guyane' >Guyane<\/option><option value='Guyane' >Guyane<\/option><option value='G\u00e9orgie' >G\u00e9orgie<\/option><option value='G\u00e9orgie du Sud et \u00celes Sandwich du Sud' >G\u00e9orgie du Sud et \u00celes Sandwich du Sud<\/option><option value='Ha\u00efti' >Ha\u00efti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hongrie' >Hongrie<\/option><option value='Inde' >Inde<\/option><option value='Indon\u00e9sie' >Indon\u00e9sie<\/option><option value='Irak' >Irak<\/option><option value='Iran' >Iran<\/option><option value='Irlande' >Irlande<\/option><option value='Islande' >Islande<\/option><option value='Isra\u00ebl' >Isra\u00ebl<\/option><option value='Italie' >Italie<\/option><option value='Jama\u00efque' >Jama\u00efque<\/option><option value='Japon' >Japon<\/option><option value='Jersey' >Jersey<\/option><option value='Jordanie' >Jordanie<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kirghizistan' >Kirghizistan<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kowe\u00eft' >Kowe\u00eft<\/option><option value='La Barbade' >La Barbade<\/option><option value='La R\u00e9union' >La R\u00e9union<\/option><option value='Lesotho' >Lesotho<\/option><option value='Lettonie' >Lettonie<\/option><option value='Liban' >Liban<\/option><option value='Liberia' >Liberia<\/option><option value='Libye' >Libye<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituanie' >Lituanie<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Mac\u00e9doine du Nord' >Mac\u00e9doine du Nord<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malaisie' >Malaisie<\/option><option value='Malawi' >Malawi<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malte' >Malte<\/option><option value='Maroc' >Maroc<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritanie' >Mauritanie<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexique' >Mexique<\/option><option value='Micron\u00e9sie' >Micron\u00e9sie<\/option><option value='Moldavie' >Moldavie<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolie' >Mongolie<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mont\u00e9n\u00e9gro' >Mont\u00e9n\u00e9gro<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibie' >Namibie<\/option><option value='Nauru' >Nauru<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nig\u00e9ria' >Nig\u00e9ria<\/option><option value='Niu\u00e9' >Niu\u00e9<\/option><option value='Norv\u00e8ge' >Norv\u00e8ge<\/option><option value='Nouvelle-Cal\u00e9donie' >Nouvelle-Cal\u00e9donie<\/option><option value='Nouvelle-Z\u00e9lande' >Nouvelle-Z\u00e9lande<\/option><option value='N\u00e9pal' >N\u00e9pal<\/option><option value='Oman' >Oman<\/option><option value='Ouganda' >Ouganda<\/option><option value='Ouzb\u00e9kistan' >Ouzb\u00e9kistan<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Panama' >Panama<\/option><option value='Papouasie-Nouvelle-Guin\u00e9e' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='Paraguay' >Paraguay<\/option><option value='Pays-Bas' >Pays-Bas<\/option><option value='Philippines' >Philippines<\/option><option value='Pologne' >Pologne<\/option><option value='Polyn\u00e9sie fran\u00e7aise' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='Porto Rico' >Porto Rico<\/option><option value='Portugal' >Portugal<\/option><option value='P\u00e9rou' >P\u00e9rou<\/option><option value='Qatar' >Qatar<\/option><option value='Roumanie' >Roumanie<\/option><option value='Royaume-Uni' >Royaume-Uni<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9publique Dominicaine' >R\u00e9publique Dominicaine<\/option><option value='R\u00e9publique Tch\u00e8que' >R\u00e9publique Tch\u00e8que<\/option><option value='R\u00e9publique arabe syrienne' >R\u00e9publique arabe syrienne<\/option><option value='R\u00e9publique centrafricaine' >R\u00e9publique centrafricaine<\/option><option value='R\u00e9publique d\u00e9mocratique du Congo' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='R\u00e9publique d\u00e9mocratique populaire du Laos' >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value='Sahara occidental' >Sahara occidental<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre et Miquelon' >Saint Pierre et Miquelon<\/option><option value='Saint-Christophe-et-Nevis' >Saint-Christophe-et-Nevis<\/option><option value='Saint-Marin' >Saint-Marin<\/option><option value='Saint-Si\u00e8ge' >Saint-Si\u00e8ge<\/option><option value='Saint-Vincent-et-les Grenadines' >Saint-Vincent-et-les Grenadines<\/option><option value='Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha' >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value='Sainte-Lucie' >Sainte-Lucie<\/option><option value='Salvador' >Salvador<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa am\u00e9ricaines' >Samoa am\u00e9ricaines<\/option><option value='Sao Tom\u00e9 et Principe' >Sao Tom\u00e9 et Principe<\/option><option value='Serbie' >Serbie<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapour' >Singapour<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovaquie' >Slovaquie<\/option><option value='Slov\u00e9nie' >Slov\u00e9nie<\/option><option value='Somalie' >Somalie<\/option><option value='Soudan' >Soudan<\/option><option value='Soudan du Sud' >Soudan du Sud<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Suisse' >Suisse<\/option><option value='Suriname' >Suriname<\/option><option value='Su\u00e8de' >Su\u00e8de<\/option><option value='S\u00e9n\u00e9gal' >S\u00e9n\u00e9gal<\/option><option value='Tadjikistan' >Tadjikistan<\/option><option value='Tanzanie (R\u00e9publique-Unie de)' >Tanzanie (R\u00e9publique-Unie de)<\/option><option value='Ta\u00efwan' >Ta\u00efwan<\/option><option value='Tchad' >Tchad<\/option><option value='Terres Australes Fran\u00e7aises' >Terres Australes Fran\u00e7aises<\/option><option value='Territoire britannique de l\u2019oc\u00e9an Indien' >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value='Tha\u00eflande' >Tha\u00eflande<\/option><option value='Timor oriental' >Timor oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinit\u00e9 et Tobago' >Trinit\u00e9 et Tobago<\/option><option value='Tunisie' >Tunisie<\/option><option value='Turkm\u00e9nistan' >Turkm\u00e9nistan<\/option><option value='Turquie' >Turquie<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Ukraine' >Ukraine<\/option><option value='Uruguay' >Uruguay<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis et Futuna' >Wallis et Futuna<\/option><option value='Y\u00e9men' >Y\u00e9men<\/option><option value='Zambie' >Zambie<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c9gypte' >\u00c9gypte<\/option><option value='\u00c9mirats arabes unis' >\u00c9mirats arabes unis<\/option><option value='\u00c9quateur' >\u00c9quateur<\/option><option value='\u00c9rythr\u00e9e' >\u00c9rythr\u00e9e<\/option><option value='\u00c9tat palestinien' >\u00c9tat palestinien<\/option><option value='\u00c9tats-Unis' >\u00c9tats-Unis<\/option><option value='\u00c9thiopie' >\u00c9thiopie<\/option><option value='\u00cele Bouvet' >\u00cele Bouvet<\/option><option value='\u00cele Christmas' >\u00cele Christmas<\/option><option value='\u00cele Maurice' >\u00cele Maurice<\/option><option value='\u00cele Norfolk' >\u00cele Norfolk<\/option><option value='\u00cele de Man' >\u00cele de Man<\/option><option value='\u00celes Cayman' >\u00celes Cayman<\/option><option value='\u00celes Cocos' >\u00celes Cocos<\/option><option value='\u00celes Cook' >\u00celes Cook<\/option><option value='\u00celes Falkland' >\u00celes Falkland<\/option><option value='\u00celes F\u00e9ro\u00e9' >\u00celes F\u00e9ro\u00e9<\/option><option value='\u00celes Heard et McDonald' >\u00celes Heard et McDonald<\/option><option value='\u00celes Mariannes du Nord' >\u00celes Mariannes du Nord<\/option><option value='\u00celes Marshall' >\u00celes Marshall<\/option><option value='\u00celes Pitcairn' >\u00celes Pitcairn<\/option><option value='\u00celes Salomon' >\u00celes Salomon<\/option><option value='\u00celes Turques et Ca\u00efques' >\u00celes Turques et Ca\u00efques<\/option><option value='\u00celes Vierges am\u00e9ricaines' >\u00celes Vierges am\u00e9ricaines<\/option><option value='\u00celes Vierges britanniques' >\u00celes Vierges britanniques<\/option><option value='\u00celes de Svalbard et Jan Mayen' >\u00celes de Svalbard et Jan Mayen<\/option><option value='\u00celes mineures am\u00e9ricaines' >\u00celes mineures am\u00e9ricaines<\/option><option value='\u00celes \u00c5land' >\u00celes \u00c5land<\/option><\/select><br \/>\n                                    <\/span><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p><\/div>\n<\/fieldset>\n<div id=\"field_4_56\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--phone gfield--large\"  data-field-class=\"gfield--phone gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_56'>Phone<\/label><\/p>\n<div class='ginput_container ginput_container_phone'><input name='input_56' id='input_4_56' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_57\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--email gfield--large\"  data-field-class=\"gfield--email gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_57'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container 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