{"id":53517,"date":"2024-10-14T16:25:58","date_gmt":"2024-10-14T14:25:58","guid":{"rendered":"https:\/\/biorius.com\/effets-indesirables-biorius\/"},"modified":"2025-11-19T13:09:36","modified_gmt":"2025-11-19T12:09:36","slug":"effets-indesirables","status":"publish","type":"page","link":"https:\/\/biorius.com\/fr\/effets-indesirables\/","title":{"rendered":"Effets ind\u00e9sirables Biorius"},"content":{"rendered":"\n<div data-elementor-type=\"wp-page\" data-elementor-id=\"53517\" class=\"elementor elementor-53517 elementor-53443\" data-elementor-post-type=\"page\">\n<div class=\"elementor-element elementor-element-dff03a5 e-flex e-con-boxed e-con e-parent\" data-id=\"dff03a5\" 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-bddeb46 elementor-widget elementor-widget-heading\" data-id=\"bddeb46\" 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\">Effet ind\u00e9sirable cosm\u00e9tique<\/h1>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-7d47fe3 elementor-widget elementor-widget-html\" data-id=\"7d47fe3\" 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\/fr\/\">Accueil<\/a>\n        <\/li>\n<li>\n            <a href=\"#\">Effet ind\u00e9sirable cosm\u00e9tique<\/a>\n        <\/li>\n<\/ul>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-b9ca7fb e-flex e-con-boxed e-con e-parent\" data-id=\"b9ca7fb\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-ddc1df5 elementor-widget elementor-widget-image\" data-id=\"ddc1df5\" 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=\"1024\" height=\"242\" src=\"https:\/\/biorius.com\/wp-content\/uploads\/2023\/11\/LOGO_RVB-1024x242.png\" class=\"attachment-large size-large wp-image-45661\" alt=\"Biorius Logo\" srcset=\"https:\/\/biorius.com\/wp-content\/uploads\/2023\/11\/LOGO_RVB-1024x242.png 1024w, https:\/\/biorius.com\/wp-content\/uploads\/2023\/11\/LOGO_RVB-300x71.png 300w, https:\/\/biorius.com\/wp-content\/uploads\/2023\/11\/LOGO_RVB-768x182.png 768w, https:\/\/biorius.com\/wp-content\/uploads\/2023\/11\/LOGO_RVB-1536x364.png 1536w, https:\/\/biorius.com\/wp-content\/uploads\/2023\/11\/LOGO_RVB.png 1799w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/>\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-49325a5 e-con-full e-flex e-con e-child\" data-id=\"49325a5\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"elementor-element elementor-element-d4d2328 elementor-widget elementor-widget-heading\" data-id=\"d4d2328\" 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\">Questionnaire du consommateur <br \/><\/h1>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-f8c4058 e-flex e-con-boxed e-con e-parent\" data-id=\"f8c4058\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-efc3a1f e-con-full e-flex e-con e-child\" data-id=\"efc3a1f\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"elementor-element elementor-element-96256d0 elementor-widget elementor-widget-text-editor\" data-id=\"96256d0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n<div class=\"elementor-widget-container\">\n<p><strong>Biorius<\/strong> est la <strong>personne responsable<\/strong> de plusieurs marques de cosm\u00e9tiques. Tant Biorius que les marques que nous repr\u00e9sentons accordent la priorit\u00e9 \u00e0 la s\u00e9curit\u00e9 des produits mis sur le march\u00e9 et restent tr\u00e8s vigilants \u00e0 cet \u00e9gard. Il est de la plus haute importance pour nous de comprendre la cause potentielle de l&#8217;effet ind\u00e9sirable que vous avez ressenti.  <\/p>\n<p>Pour nous aider \u00e0 examiner la situation de mani\u00e8re approfondie et, le cas \u00e9ch\u00e9ant, \u00e0 prendre des mesures pour am\u00e9liorer le produit, nous vous demandons de bien vouloir remplir le formulaire suivant. Les questions sont bas\u00e9es sur les lignes directrices \u00e9nonc\u00e9es dans la <strong>r\u00e9solution ResAP(2006)1 du Conseil de l&#8217;Europe<\/strong>. Une fois votre demande soumise, l&#8217;un de nos experts vous contactera par courrier \u00e9lectronique pour assurer le suivi de votre dossier.  <\/p>\n<p>Veuillez noter qu&#8217;il <strong>n&#8217;<\/strong>est <strong>pas obligatoire de<\/strong> r\u00e9pondre \u00e0 toutes les questions ou de fournir des informations compl\u00e8tes. Toutefois, plus vous fournirez de d\u00e9tails, mieux et plus vite nous pourrons vous aider. <\/p>\n<p>Les donn\u00e9es collect\u00e9es par Biorius seront trait\u00e9es dans le respect de toutes les obligations l\u00e9gales relatives \u00e0 la <strong>protection des donn\u00e9es personnelles<\/strong>.<\/p>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-d94b334 e-flex e-con-boxed e-con e-parent\" data-id=\"d94b334\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-7c25ac9 elementor-widget__width-inherit elementor-widget elementor-widget-gk_elementor_gravity_form\" data-id=\"7c25ac9\" 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_10'  action='\/fr\/wp-json\/wp\/v2\/pages\/53517' data-formid='10' novalidate>\n<div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeU9SIqAAAAAFxZQ73mH3MP9-aJLNPkaprZhj7H' data-tabindex='0'><input id=\"input_aad7e94068a873bc06ed3ec27580d45f\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_aad7e94068a873bc06ed3ec27580d45f\" value=\"\"\/><\/div>\n<div class='gform-body gform_body'>\n<div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below'>\n<div id=\"field_10_136\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below 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_10_136'>Email<\/label><\/p>\n<div class='ginput_container'><input name='input_136' id='input_10_136' type='text' value='' autocomplete='new-password'\/><\/div>\n<div class='gfield_description' id='gfield_description_10_136'>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_10_135\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below 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' >Consentement<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_135.1' id='input_10_135_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_10_135_1' >J'accepte le traitement de mes donn\u00e9es personnelles.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_135.2' value='J&#039;accepte le traitement de mes donn\u00e9es personnelles.' class='gform_hidden' \/><input type='hidden' name='input_135.3' value='1' class='gform_hidden' \/><\/div>\n<\/fieldset>\n<fieldset id=\"field_10_134\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below 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' >Consentement<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_134.1' id='input_10_134_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_10_134_1' >J'accepte que ces donn\u00e9es soient communiqu\u00e9es au distributeur et\/ou \u00e0 la marque du produit cosm\u00e9tique et\/ou aux autorit\u00e9s de mon pays.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_134.2' value='J&#039;accepte que ces donn\u00e9es soient communiqu\u00e9es au distributeur et\/ou \u00e0 la marque du produit cosm\u00e9tique et\/ou aux autorit\u00e9s de mon pays.' class='gform_hidden' \/><input type='hidden' name='input_134.3' value='1' class='gform_hidden' \/><\/div>\n<\/fieldset>\n<div id=\"field_10_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_below 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. Information des consommateurs<\/h3>\n<\/div>\n<fieldset id=\"field_10_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' >Pr\u00e9nom<\/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_10_1'>\n<p>                            <span id='input_10_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_10_1_3' value=''   aria-required='false'    autocomplete=\"given-name\" \/><br \/>\n                                                    <label for='input_10_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_10_133\" 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' >Nom de famille<\/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_10_133'>\n<p>                            <span id='input_10_133_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_133.6' id='input_10_133_6' value=''   aria-required='false'    autocomplete=\"family-name\" \/><br \/>\n                                                    <label for='input_10_133_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_10_61\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below 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_10_61'>Date de naissance<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_10_61' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_61_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_10_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_10_61' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<fieldset id=\"field_10_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below 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' >Le sexe<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_27'>\n<div class='gchoice gchoice_10_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Homme'  id='choice_10_27_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_27_1' id='label_10_27_1' class='gform-field-label gform-field-label--type-inline'>Homme<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Femme'  id='choice_10_27_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_27_2' id='label_10_27_2' class='gform-field-label gform-field-label--type-inline'>Femme<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Indiff\u00e9renci\u00e9'  id='choice_10_27_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_27_3' id='label_10_27_3' class='gform-field-label gform-field-label--type-inline'>Indiff\u00e9renci\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Refus de r\u00e9pondre'  id='choice_10_27_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_27_4' id='label_10_27_4' class='gform-field-label gform-field-label--type-inline'>Refus de r\u00e9pondre<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_132\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_132'>Adresse compl\u00e8te (facultatif)<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_132' id='input_10_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_69\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below 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_10_69'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_email'>\n                            <input name='input_69' id='input_10_69' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div>\n<\/div>\n<div id=\"field_10_122\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below 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_10_122'>T\u00e9l\u00e9phone (facultatif)<\/label><\/p>\n<div class='ginput_container ginput_container_phone'><input name='input_122' id='input_10_122' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_below 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\">Ant\u00e9c\u00e9dents m\u00e9dicaux<\/h3>\n<\/div>\n<fieldset id=\"field_10_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Avez-vous une peau sensible ou r\u00e9active ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_72'>\n<div class='gchoice gchoice_10_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Oui'  id='choice_10_72_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_72_1' id='label_10_72_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='Non'  id='choice_10_72_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_72_2' id='label_10_72_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_124\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_124'>Avez-vous d\u00e9j\u00e0 eu une r\u00e9action avec ce produit ou avec un autre produit cosm\u00e9tique ?<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_124' id='input_10_124' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<fieldset id=\"field_10_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below 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' >\u00cates-vous sensible ou allergique \u00e0<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_74'>\n<div class='gchoice gchoice_10_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Cosm\u00e9tiques'  id='choice_10_74_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_74_1' id='label_10_74_1' class='gform-field-label gform-field-label--type-inline'>Cosm\u00e9tiques<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Parfums'  id='choice_10_74_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_74_2' id='label_10_74_2' class='gform-field-label gform-field-label--type-inline'>Parfums<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='M\u00e9taux lourds'  id='choice_10_74_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_74_3' id='label_10_74_3' class='gform-field-label gform-field-label--type-inline'>M\u00e9taux lourds<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_74_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.4' type='checkbox'  value='Pollen'  id='choice_10_74_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_74_4' id='label_10_74_4' class='gform-field-label gform-field-label--type-inline'>Pollen<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below 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_10_75'>Autres substances ?<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_75' id='input_10_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<fieldset id=\"field_10_76\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below 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' >Avez-vous d\u00e9j\u00e0 souffert de<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_76'>\n<div class='gchoice gchoice_10_76_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.1' type='checkbox'  value='Asthme'  id='choice_10_76_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_76_1' id='label_10_76_1' class='gform-field-label gform-field-label--type-inline'>Asthme<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_76_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.2' type='checkbox'  value='Ecz\u00e9ma'  id='choice_10_76_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_76_2' id='label_10_76_2' class='gform-field-label gform-field-label--type-inline'>Ecz\u00e9ma<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_76_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.3' type='checkbox'  value='Rhinite'  id='choice_10_76_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_76_3' id='label_10_76_3' class='gform-field-label gform-field-label--type-inline'>Rhinite<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_76_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.4' type='checkbox'  value='Urticaire'  id='choice_10_76_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_76_4' id='label_10_76_4' class='gform-field-label gform-field-label--type-inline'>Urticaire<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_76_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.5' type='checkbox'  value='\u0152d\u00e8me de Quincke'  id='choice_10_76_5'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_76_5' id='label_10_76_5' class='gform-field-label gform-field-label--type-inline'>\u0152d\u00e8me de Quincke<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_76_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.6' type='checkbox'  value='Choc anaphylactique'  id='choice_10_76_6'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_76_6' id='label_10_76_6' class='gform-field-label gform-field-label--type-inline'>Choc anaphylactique<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_76_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_76.7' type='checkbox'  value='Intol\u00e9rance'  id='choice_10_76_7'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_76_7' id='label_10_76_7' class='gform-field-label gform-field-label--type-inline'>Intol\u00e9rance<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below 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_10_77'>Intol\u00e9rance ? (veuillez la d\u00e9crire) <\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_77' id='input_10_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_below 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. Produit suspect<\/h3>\n<\/div>\n<div id=\"field_10_131\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_131'>Nom de la marque<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_131' id='input_10_131' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_78'>Nom du produit (\u00e9tiquet\u00e9 sur votre produit)<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_78' id='input_10_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_80'>Num\u00e9ro de lot (facultatif)<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_80' id='input_10_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_79'>Dans le cas d&#039;un produit de maquillage, nom de la (des) teinte(s) concern\u00e9e(s) (\u00e9tiquet\u00e9e(s) sur votre produit)<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_79' id='input_10_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_81'>Achat de produits (pays, ville, magasin, site web)<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_81' id='input_10_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_82'>Aspect du produit : normal \/ anormal (veuillez d\u00e9crire si anormal)<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_82' id='input_10_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_below 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. Conditions d&#039;utilisation du produit<\/h3>\n<\/div>\n<div id=\"field_10_83\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below 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_10_83'>Date d&#039;achat du produit<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_83' id='input_10_83' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_83_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_10_83_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_10_83' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_10_84\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below 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_10_84'>Date de la premi\u00e8re utilisation<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_84' id='input_10_84' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_84_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_10_84_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_10_84' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_10_86\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below 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_10_86'>Date de la derni\u00e8re utilisation<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_86' id='input_10_86' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_86_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_10_86_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_10_86' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_10_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_87'>Pendant combien de temps avez-vous utilis\u00e9 le produit ?<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_87' id='input_10_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_88'>Fr\u00e9quence d&#039;utilisation (par jour, par mois ou autre)<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_88' id='input_10_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_126\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_126'>Domaine(s) d&#039;application (veuillez donner une description pr\u00e9cise de la mani\u00e8re dont vous avez appliqu\u00e9 le produit)<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_126' id='input_10_126' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_10_127\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_127'>Avez-vous d\u00e9j\u00e0 utilis\u00e9 ce produit ou un autre produit de la m\u00eame marque cosm\u00e9tique ?<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_10_127' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_10_128\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_128'>Remarques sur les conditions d&#039;utilisation : peau s\u00e8che ou ab\u00eem\u00e9e avant l&#039;utilisation, utilisation simultan\u00e9e avec d&#039;autres produits cosm\u00e9tiques ou pharmaceutiques, exposition au soleil apr\u00e8s l&#039;application, traitement m\u00e9dical...<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_128' id='input_10_128' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_10_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_below 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. Description de l&#039;effet ind\u00e9sirable<\/h3>\n<\/div>\n<div id=\"field_10_92\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_92'>Pays o\u00f9 l&#039;effet ind\u00e9sirable s&#039;est produit<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_92' id='input_10_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_93\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below 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_10_93'>Date d&#039;apparition des sympt\u00f4mes<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_93' id='input_10_93' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_93_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_10_93_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_10_93' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_10_94\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below 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_10_94'>Date de fin des sympt\u00f4mes<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_94' id='input_10_94' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/jj\/aaaa' aria-describedby=\"input_10_94_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_10_94_date_format' class='screen-reader-text'>MM slash JJ slash AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_10_94' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<fieldset id=\"field_10_96\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Sympt\u00f4mes toujours pr\u00e9sents<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_96'>\n<div class='gchoice gchoice_10_96_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.1' type='checkbox'  value='Oui'  id='choice_10_96_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_96_1' id='label_10_96_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_96_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.2' type='checkbox'  value='Non'  id='choice_10_96_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_96_2' id='label_10_96_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_123\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_123'>Apr\u00e8s combien d&#039;applications les sympt\u00f4mes sont-ils apparus ?<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_123' id='input_10_123' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<fieldset id=\"field_10_99\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Combien de temps apr\u00e8s l&#039;application la r\u00e9action s&#039;est-elle produite ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_99'>\n<div class='gchoice gchoice_10_99_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.1' type='checkbox'  value='Imm\u00e9diatement'  id='choice_10_99_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_99_1' id='label_10_99_1' class='gform-field-label gform-field-label--type-inline'>Imm\u00e9diatement<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_99_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.2' type='checkbox'  value='Moins d&#039;une heure'  id='choice_10_99_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_99_2' id='label_10_99_2' class='gform-field-label gform-field-label--type-inline'>Moins d'une heure<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_99_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.3' type='checkbox'  value='Plus d&#039;une heure'  id='choice_10_99_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_99_3' id='label_10_99_3' class='gform-field-label gform-field-label--type-inline'>Plus d'une heure<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_99_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.4' type='checkbox'  value='Un jour'  id='choice_10_99_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_99_4' id='label_10_99_4' class='gform-field-label gform-field-label--type-inline'>Un jour<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_99_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.5' type='checkbox'  value='Plus d&#039;un jour'  id='choice_10_99_5'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_99_5' id='label_10_99_5' class='gform-field-label gform-field-label--type-inline'>Plus d'un jour<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_10_101\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Combien de temps cette r\u00e9action a-t-elle dur\u00e9 ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_101'>\n<div class='gchoice gchoice_10_101_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.1' type='checkbox'  value='Quelques heures'  id='choice_10_101_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_101_1' id='label_10_101_1' class='gform-field-label gform-field-label--type-inline'>Quelques heures<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_101_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.2' type='checkbox'  value='Un jour'  id='choice_10_101_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_101_2' id='label_10_101_2' class='gform-field-label gform-field-label--type-inline'>Un jour<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_101_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_101.3' type='checkbox'  value='Plus d&#039;un jour'  id='choice_10_101_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_101_3' id='label_10_101_3' class='gform-field-label gform-field-label--type-inline'>Plus d'un jour<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_102\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_102'>Description de l&#039;effet ind\u00e9sirable survenu (sensations, apparence, douleur, ...) ? Veuillez donner une description d\u00e9taill\u00e9e des sympt\u00f4mes et des zones de r\u00e9action. Tous les d\u00e9tails peuvent \u00eatre importants.  <\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_102' id='input_10_102' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<fieldset id=\"field_10_103\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Avez-vous cess\u00e9 d&#039;utiliser le produit ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_103'>\n<div class='gchoice gchoice_10_103_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.1' type='checkbox'  value='Oui'  id='choice_10_103_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_103_1' id='label_10_103_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_103_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_103.2' type='checkbox'  value='Non'  id='choice_10_103_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_103_2' id='label_10_103_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_129\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_129'>Comment les sympt\u00f4mes ont-ils \u00e9volu\u00e9 dans les heures et les jours qui ont suivi ?<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_129' id='input_10_129' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_10_130\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_130'>Qu&#039;avez-vous fait pour que cela s&#039;arr\u00eate ?<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_130' id='input_10_130' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<fieldset id=\"field_10_108\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Avez-vous consult\u00e9 un professionnel de la sant\u00e9 ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_108'>\n<div class='gchoice gchoice_10_108_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.1' type='checkbox'  value='Oui'  id='choice_10_108_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_108_1' id='label_10_108_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_108_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_108.2' type='checkbox'  value='Non'  id='choice_10_108_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_108_2' id='label_10_108_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_109\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_109'>Dans l&#039;affirmative, veuillez indiquer la date de la consultation ainsi que le nom et l&#039;adresse du professionnel de la sant\u00e9.<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_109' id='input_10_109' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_10_111\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_111'>Si oui, quel \u00e9tait son diagnostic ?<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_111' id='input_10_111' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<fieldset id=\"field_10_106\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Avez-vous eu recours \u00e0 un traitement m\u00e9dical ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_106'>\n<div class='gchoice gchoice_10_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' type='checkbox'  value='Oui'  id='choice_10_106_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_106_1' id='label_10_106_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_106_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.2' type='checkbox'  value='Non'  id='choice_10_106_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_106_2' id='label_10_106_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_107'>Si oui, veuillez indiquer le nom des m\u00e9dicaments<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_107' id='input_10_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<fieldset id=\"field_10_112\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Avez-vous r\u00e9appliqu\u00e9 le produit apr\u00e8s la disparition des sympt\u00f4mes ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_112'>\n<div class='gchoice gchoice_10_112_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.1' type='checkbox'  value='Oui'  id='choice_10_112_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_1' id='label_10_112_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_112_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_112.2' type='checkbox'  value='Non'  id='choice_10_112_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_112_2' id='label_10_112_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_10_113\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >La nouvelle demande a-t-elle \u00e9t\u00e9 pr\u00e9sent\u00e9e de la m\u00eame mani\u00e8re ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_113'>\n<div class='gchoice gchoice_10_113_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.1' type='checkbox'  value='Oui'  id='choice_10_113_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_113_1' id='label_10_113_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_113_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_113.2' type='checkbox'  value='Non'  id='choice_10_113_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_113_2' id='label_10_113_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_10_114\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Les sympt\u00f4mes sont-ils r\u00e9apparus ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_114'>\n<div class='gchoice gchoice_10_114_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.1' type='checkbox'  value='Oui'  id='choice_10_114_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_114_1' id='label_10_114_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_114_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_114.2' type='checkbox'  value='Non'  id='choice_10_114_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_114_2' id='label_10_114_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_115\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below 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_10_115'>Les sympt\u00f4mes ont-ils \u00e9t\u00e9 les m\u00eames que lors de la premi\u00e8re r\u00e9action ?<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_115' id='input_10_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<fieldset id=\"field_10_116\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Avez-vous \u00e9t\u00e9 hospitalis\u00e9 \u00e0 la suite de cet \u00e9v\u00e9nement ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_116'>\n<div class='gchoice gchoice_10_116_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.1' type='checkbox'  value='Oui'  id='choice_10_116_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_116_1' id='label_10_116_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_116_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_116.2' type='checkbox'  value='Non'  id='choice_10_116_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_116_2' id='label_10_116_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_10_118\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Si oui, a-t-elle dur\u00e9 plus de 24 heures ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_118'>\n<div class='gchoice gchoice_10_118_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.1' type='checkbox'  value='Oui'  id='choice_10_118_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_118_1' id='label_10_118_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_118_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_118.2' type='checkbox'  value='Non'  id='choice_10_118_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_118_2' id='label_10_118_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_10_117\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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' >Avez-vous eu un arr\u00eat de travail li\u00e9 \u00e0 cet \u00e9v\u00e9nement ?<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_10_117'>\n<div class='gchoice gchoice_10_117_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.1' type='checkbox'  value='Oui'  id='choice_10_117_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_117_1' id='label_10_117_1' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_10_117_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_117.2' type='checkbox'  value='Non'  id='choice_10_117_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_117_2' id='label_10_117_2' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_10_119\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--fileupload gfield--large\"  data-field-class=\"gfield--fileupload gfield--large\" ><label class='gfield_label gform-field-label' for='gform_browse_button_10_119'>Si vous disposez d&#039;une ordonnance, d&#039;un arr\u00eat de travail, d&#039;un certificat m\u00e9dical, d&#039;un rapport d&#039;admission aux urgences, d&#039;un rapport d&#039;hospitalisation li\u00e9s \u00e0 l&#039;effet ind\u00e9sirable, pourriez-vous les joindre ?<\/label><\/p>\n<div class='ginput_container ginput_container_fileupload'>\n<div id='gform_multifile_upload_10_119' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_10_119&quot;,&quot;container&quot;:&quot;gform_multifile_upload_10_119&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_10_119&quot;,&quot;filelist&quot;:&quot;gform_preview_10_119&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/biorius.com\\\/fr\\\/?gf_page=a0b2b301dc2d428&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/biorius.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/biorius.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;52428800b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:10,&quot;field_id&quot;:119,&quot;_gform_file_upload_nonce_10_119&quot;:&quot;b88d1fd0a7&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_10_119&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n<div id='gform_drag_drop_area_10_119' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span><br \/>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_10_119' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_10_119\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<p><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_119'>Taille max. des fichiers\u00a0: 50 MB.<\/span><\/p>\n<ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_10_119'><\/ul>\n<div id='gform_preview_10_119' class='ginput_preview_list'><\/div>\n<\/div>\n<\/div>\n<div id=\"field_10_120\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--fileupload gfield--large\"  data-field-class=\"gfield--fileupload gfield--large\" ><label class='gfield_label gform-field-label' for='gform_browse_button_10_120'>Si vous avez des photos du produit et\/ou de l&#039;effet ind\u00e9sirable, pourriez-vous les joindre ?<\/label><\/p>\n<div class='ginput_container ginput_container_fileupload'>\n<div id='gform_multifile_upload_10_120' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_10_120&quot;,&quot;container&quot;:&quot;gform_multifile_upload_10_120&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_10_120&quot;,&quot;filelist&quot;:&quot;gform_preview_10_120&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/biorius.com\\\/fr\\\/?gf_page=a0b2b301dc2d428&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/biorius.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/biorius.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Fichiers autoris\\u00e9s&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;52428800b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:10,&quot;field_id&quot;:120,&quot;_gform_file_upload_nonce_10_120&quot;:&quot;ade69f6267&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_10_120&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n<div id='gform_drag_drop_area_10_120' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>D\u00e9posez les fichiers ici ou <\/span><br \/>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_10_120' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_10_120\"  >S\u00e9lectionnez des fichiers<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<p><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_10_120'>Taille max. des fichiers\u00a0: 50 MB.<\/span><\/p>\n<ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_10_120'><\/ul>\n<div id='gform_preview_10_120' class='ginput_preview_list'><\/div>\n<\/div>\n<\/div>\n<div id=\"field_10_121\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below 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_10_121'>Avez-vous d&#039;autres commentaires ou questions ?<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_121' id='input_10_121' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_10' class='gform_button button gform-button--width-full' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Soumettre'  \/><br \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_10' value='postback' \/><br \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_10' id='gform_theme_10' 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