{"id":3409,"date":"2026-04-28T12:29:40","date_gmt":"2026-04-28T12:29:40","guid":{"rendered":"https:\/\/physimed.com\/?page_id=3409"},"modified":"2026-05-19T15:20:14","modified_gmt":"2026-05-19T15:20:14","slug":"medical-referral-form","status":"publish","type":"page","link":"https:\/\/physimed.com\/en\/formulaire-de-reference-medicale\/","title":{"rendered":"MEDICAL REFERRAL FORM<style>.wp-block-post-title, .entry-title {\u00a0\u00a0\u00a0 text-align: center;\u00a0\u00a0\u00a0 margin-left: auto;\u00a0\u00a0\u00a0 margin-right: auto;}<\/style>"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3409\" class=\"elementor elementor-3409\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6580bc e-flex e-con-boxed e-con e-parent\" data-id=\"6580bc\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-166adfc elementor-widget elementor-widget-text-editor\" data-id=\"166adfc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t\n<p><style>\n.wp-block-post-title, .entry-title {\n    text-align: center;\n    margin-left: auto;\n    margin-right: auto;\n    margin-top: 40px; \n}\n<\/style><\/p>\n<div class='fluentform ff-default fluentform_wrapper_12 ffs_default_wrap'>\n<form data-form_id=\"12\" id=\"fluentform_12\" class=\"frm-fluent-form fluent_form_12 ff-el-form-top ff_form_instance_12_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_12_1\" method=\"POST\" >\n<fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n<legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">FORMULAIRE DE R\u00c9F\u00c9RENCE M\u00c9DICALE \/ MEDICAL REFERRAL FORM<\/legend>\n<p><input type='hidden' name='__fluent_form_embded_post_id' value='3409' \/><input type=\"hidden\" id=\"_fluentform_12_fluentformnonce\" name=\"_fluentform_12_fluentformnonce\" value=\"53fae68dd3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/3409\" \/><\/p>\n<div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-12_1\" >\n<div class=\"physimed-form-logo\" style=\"text-align:center\">\n  <img decoding=\"async\" src=\"https:\/\/physimed.com\/wp-content\/uploads\/2026\/05\/continuum.png\" alt=\"Continuum Physimed\" style=\"width:300px;max-width:100%;height:auto;display:block;margin:auto\" \/>\n<\/div>\n<\/div>\n<div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-12_2\" >\n<h3 class='ff-el-section-title'>Informations du patient \/ Patient Information<\/h3>\n<div class='ff-section_break_desk'>\n<p>Veuillez remplir les informations du patient \u00e0 r\u00e9f\u00e9rer<\/p>\n<p><em>Please fill in the information for the patient to be referred<\/em><\/p>\n<\/div>\n<hr \/>\n<\/div>\n<div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_1 '>\n<div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'>\n<div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" >\n<div class='ff-t-container'>\n<div class='ff-t-cell '>\n<div class='ff-el-group ff-el-form-top'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_12_names_first_name_' id='label_ff_12_names_first_name_' >Pr\u00e9nom \/ Name<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_12_names_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<\/div>\n<div class='ff-t-cell '>\n<div class='ff-el-group ff-el-form-top'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_12_names_last_name_' id='label_ff_12_names_last_name_' >Nom \/ Surname<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_12_names_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_email' id='label_ff_12_email' aria-label=\"Courriel \/ Email\">Courriel \/ Email<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_12_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div>\n<\/div>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_phone' id='label_ff_12_phone' aria-label=\"T\u00e9l\u00e9phone \/ Phone\">T\u00e9l\u00e9phone \/ Phone<\/label><\/div>\n<div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone\" id=\"ff_12_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-12_3\" >\n<h3 class='ff-el-section-title'>Informations du m\u00e9decin r\u00e9f\u00e9rent \/ Information from the referring physician <\/h3>\n<div class='ff-section_break_desk'>\n<p>Veuillez indiquer les informations du m\u00e9decin ou de la clinique r\u00e9f\u00e9rente<\/p>\n<p><em>Please provide the contact information for the doctor or clinic that referred you<\/em><\/p>\n<\/div>\n<hr \/>\n<\/div>\n<div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_1 '>\n<div class='ff-t-cell ff-t-column-1' style='flex-basis: 100%;'>\n<div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" >\n<div class='ff-t-container'>\n<div class='ff-t-cell '>\n<div class='ff-el-group ff-el-form-top'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_12_names_1_first_name_' id='label_ff_12_names_1_first_name_' >Pr\u00e9nom \/ Name<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_12_names_1_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<\/div>\n<div class='ff-t-cell '>\n<div class='ff-el-group ff-el-form-top'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_12_names_1_last_name_' id='label_ff_12_names_1_last_name_' >Nom \/ Surname<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"names_1[last_name]\" id=\"ff_12_names_1_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2 '>\n<div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_input_text' id='label_ff_12_input_text' aria-label=\"Clinique \/ Clinic\">Clinique \/ Clinic<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_12_input_text\"  aria-invalid=\"false\" aria-required=true><\/div>\n<\/div>\n<\/div>\n<div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label asterisk-right\"><label for='ff_12_numeric_field' id='label_ff_12_numeric_field' aria-label=\"Num\u00e9ro de permis \/ License #\">Num\u00e9ro de permis \/ License #<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field\" id=\"ff_12_numeric_field\" class=\"ff-el-form-control\" data-name=\"numeric_field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=false><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2 '>\n<div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_12_input_text_1' id='label_ff_12_input_text_1' aria-label=\"Fax\">Fax<\/label><\/div>\n<div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_12_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div>\n<\/div>\n<\/div>\n<div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'>\n<div class='ff-el-group'>\n<div class=\"ff-el-input--label 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