{"id":38,"date":"2020-11-30T17:02:49","date_gmt":"2020-11-30T22:02:49","guid":{"rendered":"https:\/\/byward.flywheelsites.com\/?page_id=38"},"modified":"2025-11-18T12:11:01","modified_gmt":"2025-11-18T17:11:01","slug":"formulaire-de-paiement-en-ligne","status":"publish","type":"page","link":"https:\/\/payment.santenationhealth.ca\/fr\/","title":{"rendered":"Formulaire de paiement en ligne"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"38\" class=\"elementor elementor-38 elementor-2\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6dadd1d elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"6dadd1d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-702441f\" data-id=\"702441f\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-35c4e65 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"35c4e65\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-a1744dc\" data-id=\"a1744dc\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-94e7e20 elementor-widget elementor-widget-heading\" data-id=\"94e7e20\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Payez votre facture aujourd'hui<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-93f5cb4 elementor-position-left elementor-widget__width-initial elementor-widget-tablet__width-inherit elementor-view-default elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"93f5cb4\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 95.8 92.5\"><path d=\"m89.8.8h-84.3c-2.6 0-4.7 2.1-4.7 4.7v81.3c0 2.6 2.1 4.7 4.7 4.7h84.4c2.6 0 4.7-2.1 4.7-4.7v-81.3c-.1-2.6-2.2-4.7-4.8-4.7m-84.3 3.1h84.4c.9 0 1.6.7 1.6 1.6v7.8h-87.6v-7.8c0-.9.7-1.6 1.6-1.6m84.3 84.4h-84.3c-.9 0-1.6-.7-1.6-1.6v-70.3h87.5v70.3c0 .9-.7 1.6-1.6 1.6\" fill=\"#152d29\"><\/path><path d=\"m22.6 8.6c0 2.1-3.1 2.1-3.1 0s3.1-2.1 3.1 0\" fill=\"#152d29\"><\/path><path d=\"m16.4 8.6c0 2.1-3.1 2.1-3.1 0s3.1-2.1 3.1 0\" fill=\"#152d29\"><\/path><path d=\"m10.1 8.6c0 2.1-3.1 2.1-3.1 0s3.1-2.1 3.1 0\" fill=\"#152d29\"><\/path><g fill=\"#96c93d\"><path d=\"m39.8 25.8h15.6c.9 0 1.6-.7 1.6-1.6s-.7-1.6-1.6-1.6h-15.6c-.9 0-1.6.7-1.6 1.6.1.9.8 1.6 1.6 1.6\"><\/path><path d=\"m66.4 28.9h-37.5c-.9 0-1.6.7-1.6 1.6v6.2c0 .4.2.8.5 1.1s.7.5 1.1.5h37.5c.4 0 .8-.2 1.1-.5s.5-.7.5-1.1v-6.2c0-.4-.2-.8-.5-1.1s-.7-.5-1.1-.5zm-1.6 6.3h-34.3v-3.1h34.4v3.1z\"><\/path><path d=\"m66.4 41.4h-37.5c-.9 0-1.6.7-1.6 1.6v6.2c0 .4.2.8.5 1.1s.7.5 1.1.5h37.5c.4 0 .8-.2 1.1-.5s.5-.7.5-1.1v-6.2c0-.4-.2-.8-.5-1.1s-.7-.5-1.1-.5zm-1.6 6.3h-34.3v-3.1h34.4v3.1z\"><\/path><path d=\"m66.4 53.9h-37.5c-.9 0-1.6.7-1.6 1.6v12.5c0 .4.2.8.5 1.1s.7.5 1.1.5h37.5c.4 0 .8-.2 1.1-.5s.5-.7.5-1.1v-12.5c0-.4-.2-.8-.5-1.1s-.7-.5-1.1-.5zm-1.6 12.5h-34.3v-9.4h34.4v9.4z\"><\/path><path d=\"m50.8 72.7h-6.2c-2.6 0-4.7 2.1-4.7 4.7s2.1 4.7 4.7 4.7h6.2c2.6 0 4.7-2.1 4.7-4.7s-2.1-4.7-4.7-4.7m0 6.2h-6.2c-.9 0-1.6-.7-1.6-1.6s.7-1.6 1.6-1.6h6.2c.9 0 1.6.7 1.6 1.6-.1.9-.8 1.6-1.6 1.6\"><\/path><\/g><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<span  >\n\t\t\t\t\t\t\tRemplir le formulaire\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tPour remplir le formulaire, vous devez avoir votre num\u00e9ro de facture en main.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3208d66 elementor-position-left elementor-widget__width-initial elementor-widget-tablet__width-inherit elementor-view-default elementor-mobile-position-top elementor-widget elementor-widget-icon-box\" data-id=\"3208d66\" data-element_type=\"widget\" data-widget_type=\"icon-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-box-wrapper\">\n\n\t\t\t\t\t\t<div class=\"elementor-icon-box-icon\">\n\t\t\t\t<span  class=\"elementor-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 95.8 92.5\"><g fill=\"#152d29\"><path d=\"m90.3.9h-84.3c-2.6 0-4.7 2.1-4.7 4.7v81.3c0 2.6 2.1 4.7 4.7 4.7h84.4c2.6 0 4.7-2.1 4.7-4.7v-81.3c-.1-2.6-2.2-4.7-4.8-4.7m-84.3 3.1h84.4c.9 0 1.6.7 1.6 1.6v7.8h-87.6v-7.8c0-.9.7-1.6 1.6-1.6m84.3 84.4h-84.3c-.9 0-1.6-.7-1.6-1.6v-70.3h87.5v70.3c0 .9-.7 1.6-1.6 1.6\"><\/path><path d=\"m23.2 8.7c0 2.1-3.1 2.1-3.1 0-.1-2.1 3.1-2.1 3.1 0\"><\/path><path d=\"m16.9 8.7c0 2.1-3.1 2.1-3.1 0s3.1-2.1 3.1 0\"><\/path><path d=\"m10.7 8.7c0 2.1-3.1 2.1-3.1 0-.1-2.1 3.1-2.1 3.1 0\"><\/path><\/g><path d=\"m55 43.5c-2.1-2.7-4.1-2.6-5.4-2.1-1.1.4-1.9 1.2-2.5 2.1-.4.7-.7 2 0 3.7.3.7 1.4 2.9 3.7 7 .4.8.8 1.6 1.3 2.3l-1.3 2.1c-.2.4-.6.6-1 .8-.1 0-.2 0-.3.1-.3 0-.7 0-1-.2l-27-16c-.8-.5-1.1-1.5-.6-2.3l9.4-15.7c.5-.8 1.5-1 2.3-.6l27 16.1c.8.5 1.1 1.5.6 2.3l-2.4 3.9zm1.4 21.2c.1.3.2.6.2.9-1.1-.3-3.1-.9-3.4-1.3-.2-.4-.6-.9-1-1.5s-.8-1.2-1.2-1.8c.5-.3.9-.7 1.2-1.2l.7-1.2c1.8 2.9 3.2 5.4 3.5 6.1m-3.3 5.1c-.8-.4-4.4-4.5-5.2-5.6-.4-.6-.3-1.5.3-2 .3-.3.8-.5 1.3-.4.4.7.8 1.4 1.3 2 .4.5.7 1 .9 1.3.7 1.3 3.9 2.1 5.1 2.4v1c0 .5-.1 1 0 1.5-1.7.1-3.3 0-3.7-.2m24.4 9.5c-.4-2.5-4-24.1-4.8-26.2l-.2-.4c-.8-1.9-1.7-4.1-3.8-5-1.4-.6-5.6-2-7.6-2.7l.6-1.1c1-1.7.4-3.8-1.2-4.8l-27-16c-1.7-1-3.8-.4-4.8 1.2l-9.4 15.7c-1 1.7-.4 3.8 1.2 4.8l26.6 15.8c-.1.1-.1.1-.2.2-1.2 1.1-1.5 2.9-.5 4.3.6.9 4.6 5.7 6 6.3.7.3 2 .3 3.1.3h1.3c.4 2.3 1 4.3 2.5 6.3 1 1.3 2.3 2.3 3.7 3.1.1.1.3.1.4.1.4 0 .8-.3.9-.7s-.1-.8-.5-1c-1.2-.7-2.2-1.5-3.1-2.6-1.3-1.7-1.8-3.3-2.1-5.5-.1-1-.1-1.9 0-2.9.1-1.7.2-3.4-.5-4.7-.4-.7-1.7-3.3-3.4-6.2-.7-1.4-1.5-2.8-2.3-4.2-1.4-2.5-3.2-6-3.6-6.9-.4-.7-.4-1.5-.1-2.2.4-.6.9-1 1.5-1.3 1-.4 2.2.1 3.3 1.5l11.1 14 1.4-1.1-7-8.9 1.1-1.9c1.8.6 6.4 2.2 7.9 2.8 1.4.6 2.1 2.2 2.8 4l.2.4c.6 1.4 3.1 16.2 4.7 25.8.1.4.5.8.9.8h.1c.2 0 .5-.2.6-.4.2-.2.2-.4.2-.7\" fill=\"#96c93d\"><\/path><path d=\"m31.5 33.4 3.4 2-1.6 2.6-3.3-2zm-2.5 4.2 3.4 2c.3.2.6.3.9.3.2 0 .3 0 .5-.1.5-.1.9-.4 1.1-.8l1.5-2.5c.5-.9.2-2-.6-2.5l-3.3-2c-.9-.5-2-.2-2.5.6l-1.6 2.4c-.5.9-.2 2 .6 2.6\" fill=\"#96c93d\"><\/path><path d=\"m37.3 46.7-11-6.5c-.4-.2-.9 0-1.2.4-.2.4-.1.9.3 1.2l11 6.5c.1.1.3.1.5.1.4 0 .8-.3.9-.7 0-.4-.1-.8-.5-1\" fill=\"#96c93d\"><\/path><path d=\"m42.8 49.9-3.2-1.9c-.2-.2-.5-.2-.7-.2-.3.1-.5.2-.6.4s-.2.5-.1.7.3.5.5.6l3.2 1.9c.1.1.3.1.5.1.4 0 .8-.3.9-.7 0-.3-.2-.7-.5-.9\" fill=\"#96c93d\"><\/path><\/svg>\t\t\t\t<\/span>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t\t\t\t<div class=\"elementor-icon-box-content\">\n\n\t\t\t\t\t\t\t\t\t<h3 class=\"elementor-icon-box-title\">\n\t\t\t\t\t\t<span  >\n\t\t\t\t\t\t\tPayez avec votre carte de cr\u00e9dit\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/h3>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<p class=\"elementor-icon-box-description\">\n\t\t\t\t\t\tPour effectuer le paiement, vous devez avoir votre carte de cr\u00e9dit en main.\t\t\t\t\t<\/p>\n\t\t\t\t\n\t\t\t<\/div>\n\t\t\t\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-741fcd0\" data-id=\"741fcd0\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-490041e elementor-widget elementor-widget-shortcode\" data-id=\"490041e\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework payment_form_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' ><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3' class='payment_form' action='\/fr\/wp-json\/wp\/v2\/pages\/38#gf_3' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_28\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_28'>Company<\/label><div class='ginput_container'><input name='input_28' id='input_3_28' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_28'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Coordonn\u00e9es du patient<\/h2><\/li><li id=\"field_3_26\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_26'>Pr\u00e9nom du patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_3_26' type='text' value='' class='medium'    placeholder='Pr\u00e9nom du patient*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_27\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_27'>Nom de famille du patient<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_3_27' type='text' value='' class='medium'    placeholder='Nom de famille du patient*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informations sur la facture<\/h2><\/li><li id=\"field_3_14\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_14'>Num\u00e9ro de facture<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_3_14' type='text' value='' class='medium'    placeholder='Num\u00e9ro de facture*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_21\" class=\"gfield gfield--type-product gfield--input-type-price half gfield_price gfield_price_3_21 gfield_product_3_21 gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_21'>Montant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_21' id='input_3_21' type='text' value='' class='medium ginput_amount'  placeholder='Montant*' aria-required=\"true\" aria-invalid=\"false\"  \/>\n\t\t\t\t<\/div><\/li><li id=\"field_3_25\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Coordonn\u00e9es de facturation<\/h2><\/li><li id=\"field_3_2\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_2'>Pr\u00e9nom<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_3_2' type='text' value='' class='medium'    placeholder='Pr\u00e9nom*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_3\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_3'>Nom de famille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_3_3' type='text' value='' class='medium'    placeholder='Nom de famille*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_4\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>T\u00e9l\u00e9phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='medium'    placeholder='T\u00e9l\u00e9phone*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_23\" class=\"gfield gfield--type-email gfield--input-type-email half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_23'>Courriel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_23' id='input_3_23' type='email' value='' class='medium'   placeholder='Courriel*' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Adresse de facturation<\/h2><\/li><li id=\"field_3_7\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Num\u00e9ro de maison et nom de rue<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_3_7' type='text' value='' class='medium'    placeholder='Num\u00e9ro de maison et nom de rue*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_8\" class=\"gfield gfield--type-text gfield--input-type-text half field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Appartement, suite, unit\u00e9 etc. (facultatif)<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_3_8' type='text' value='' class='medium'    placeholder='Appartement, suite, unit\u00e9 etc. (facultatif)'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_9\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_9'>Ville<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_3_9' type='text' value='' class='medium'    placeholder='Ville*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_10\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_10'>Province<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_3_10' type='text' value='' class='medium'    placeholder='Province*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_11\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_11'>Code postal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_3_11' type='text' value='' class='medium'    placeholder='Code postal*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_12\" class=\"gfield gfield--type-text gfield--input-type-text half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_12'>Pays<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_3_12' type='text' value='' class='medium'    placeholder='Pays*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Informations sur la carte de cr\u00e9dit<\/h2><\/li><li id=\"field_3_22\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_3_22_1'>Credit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_3_22'><span class='ginput_full gform-grid-col' id='input_3_22_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_3_22_supported_creditcards'>Cartes bancaires prises en charge\u00a0: MasterCard, Visa<\/span><\/div>\n                                    <input type='text' name='input_22.1' id='input_3_22_1' value=''   onchange='gformMatchCard(\"input_3_22_1\");' onkeyup='gformMatchCard(\"input_3_22_1\");' autocomplete='off' pattern='[0-9]*' title='Seuls les chiffres sont autoris\u00e9s' placeholder='Num\u00e9ro de carte' aria-required='true'  \/>\n                                    <label for='input_3_22_1' id='input_3_22_1_label' class='gform-field-label gform-field-label--type-sub '>Num\u00e9ro de carte<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_3_22_2_container'>\n                                            <span class='ginput_cardinfo_left' id='input_3_22_2_cardinfo_left'>\n                                                <span class='ginput_card_expiration_container ginput_card_field'>\n                                                    \n                                                       <select name='input_22.2[]' id='input_3_22_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Mois<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                       \n                                                   \n                                                   \n                                                       <select name='input_22.2[]' id='input_3_22_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Ann\u00e9e<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                       \n                                                       \n                                                <\/span>\n                                                 <label for='input_3_22_2_month' class='gform-field-label gform-field-label--type-sub '>Date d&#039;expiration<\/label>\n                                            <\/span><span class='ginput_cardinfo_right gform-grid-col' id='input_3_22_2_cardinfo_right'>\n                                                <input type='text' name='input_22.3' id='input_3_22_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Seuls les chiffres sont autoris\u00e9s' placeholder='CVV' aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                                <label for='input_3_22_3' class='gform-field-label gform-field-label--type-sub '>CVV<\/label>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_3_22_5_container'>\n                                            <input type='text' name='input_22.5' id='input_3_22_5' value=''   placeholder='Nom du d\u00e9tenteur' aria-required='false'  \/>\n                       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href=\"https:\/\/santenationhealth.ca\/clinic\/#policies\" target=\"_blank\">politique de paiement<\/a> et cocher pour confirmer votre consentement.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_24.2' value='Lire la &lt;a href=&quot;https:\/\/santenationhealth.ca\/clinic\/#policies&quot; target=&quot;_blank&quot;&gt;politique de paiement&lt;\/a&gt; et cocher pour confirmer votre consentement.' class='gform_hidden' \/><input type='hidden' name='input_24.3' value='3' class='gform_hidden' \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Envoyer'  \/> <input type='hidden' name='gform_ajax' value='form_id=3&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=fa7e2a7274fdb93b62c2b9726be68458' \/>\n   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jQuery(document).on(\"input\",\"#input_4_21\", function(e){\n        jQuery(\"#input_4_21\").val((e.target.value).replaceAll(\",\",\".\"));\n    });\n    \n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Payez votre facture aujourd&rsquo;hui Remplir le formulaire Pour remplir le formulaire, vous devez avoir votre num\u00e9ro de facture en main. Payez avec votre carte de cr\u00e9dit Pour effectuer le paiement, vous devez avoir votre carte de cr\u00e9dit en main.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-38","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/pages\/38","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/comments?post=38"}],"version-history":[{"count":19,"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/pages\/38\/revisions"}],"predecessor-version":[{"id":402,"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/pages\/38\/revisions\/402"}],"wp:attachment":[{"href":"https:\/\/payment.santenationhealth.ca\/fr\/wp-json\/wp\/v2\/media?parent=38"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}