{"id":1211,"date":"2024-07-31T10:38:39","date_gmt":"2024-07-31T08:38:39","guid":{"rendered":"https:\/\/plateforme.hopital-foch.com\/?page_id=1211"},"modified":"2024-08-02T15:52:03","modified_gmt":"2024-08-02T13:52:03","slug":"patients-internationaux","status":"publish","type":"page","link":"https:\/\/plateforme.hopital-foch.com\/fr\/patients-internationaux\/","title":{"rendered":"Patients internationaux"},"content":{"rendered":"<script type=\"text\/javascript\">var 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value=\"Tuvalu\">Tuvalu<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Wallis et Futuna\">Wallis et Futuna<\/option><option value=\"Y\u00e9men\">Y\u00e9men<\/option><option value=\"Zambie\">Zambie<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><option value=\"\u00c9gypte\">\u00c9gypte<\/option><option value=\"\u00c9mirats arabes unis\">\u00c9mirats arabes unis<\/option><option value=\"\u00c9quateur\">\u00c9quateur<\/option><option value=\"\u00c9rythr\u00e9e\">\u00c9rythr\u00e9e<\/option><option value=\"\u00c9tat palestinien\">\u00c9tat palestinien<\/option><option value=\"\u00c9tats-Unis\">\u00c9tats-Unis<\/option><option value=\"\u00c9thiopie\">\u00c9thiopie<\/option><option value=\"\u00cele Bouvet\">\u00cele Bouvet<\/option><option value=\"\u00cele Christmas\">\u00cele Christmas<\/option><option value=\"\u00cele Maurice\">\u00cele Maurice<\/option><option value=\"\u00cele Norfolk\">\u00cele Norfolk<\/option><option value=\"\u00cele de Man\">\u00cele de Man<\/option><option value=\"\u00celes Cayman\">\u00celes Cayman<\/option><option value=\"\u00celes Cocos\">\u00celes Cocos<\/option><option value=\"\u00celes Cook\">\u00celes Cook<\/option><option value=\"\u00celes Falkland\">\u00celes Falkland<\/option><option value=\"\u00celes F\u00e9ro\u00e9\">\u00celes F\u00e9ro\u00e9<\/option><option value=\"\u00celes Heard et McDonald\">\u00celes Heard et McDonald<\/option><option value=\"\u00celes Mariannes du Nord\">\u00celes Mariannes du Nord<\/option><option value=\"\u00celes Marshall\">\u00celes Marshall<\/option><option value=\"\u00celes Pitcairn\">\u00celes Pitcairn<\/option><option value=\"\u00celes Salomon\">\u00celes Salomon<\/option><option value=\"\u00celes Turques et Ca\u00efques\">\u00celes Turques et Ca\u00efques<\/option><option value=\"\u00celes Vierges am\u00e9ricaines\">\u00celes Vierges am\u00e9ricaines<\/option><option value=\"\u00celes Vierges britanniques\">\u00celes Vierges britanniques<\/option><option value=\"\u00celes de Svalbard et Jan Mayen\">\u00celes de Svalbard et Jan Mayen<\/option><option value=\"\u00celes mineures am\u00e9ricaines\">\u00celes mineures am\u00e9ricaines<\/option><option value=\"\u00celes \u00c5land\">\u00celes \u00c5land<\/option><\/select>\n                                        <label for=\"input_26_6_6\" id=\"input_26_6_6_label\" class=\"gform-field-label gform-field-label--type-sub \">Pays<\/label>\n                                    <\/span>\n                    <div class=\"gf_clear gf_clear_complex\"><\/div>\n                <\/div><\/fieldset><div id=\"field_26_7\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_7\"><label class=\"gfield_label gform-field-label\" for=\"input_26_7\">Nationalit\u00e9<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_26_7\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_26_8\" class=\"gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_8\"><label class=\"gfield_label gform-field-label\" for=\"input_26_8\">T\u00e9l\u00e9phone portable<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_phone\"><input name=\"input_8\" id=\"input_26_8\" type=\"tel\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"><\/div><\/div><div id=\"field_26_9\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_9\"><label class=\"gfield_label gform-field-label\" for=\"input_26_9\">E\u2011mail<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_9\" id=\"input_26_9\" type=\"email\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\">\n                        <\/div><\/div><div id=\"field_26_10\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_10\"><label class=\"gfield_label gform-field-label\" for=\"input_26_10\">Profession actuelle (ou ancienne si retrait\u00e9)<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_26_10\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_26_11\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_11\"><h3 class=\"gsection_title\">Raison de la demande de rendez-vous<\/h3><\/div><fieldset id=\"field_26_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_36\"><legend class=\"gfield_label gform-field-label\">Le patient a \u00e9t\u00e9 renvoy\u00e9 vers l\u2019H\u00f4pital Foch par&nbsp;:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_26_36\">\n\t\t\t<div class=\"gchoice gchoice_26_36_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_36\" type=\"radio\" value=\"Par un autre m\u00e9decin r\u00e9f\u00e9rent\" id=\"choice_26_36_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_36_0\" id=\"label_26_36_0\" class=\"gform-field-label gform-field-label--type-inline\">Par un autre m\u00e9decin r\u00e9f\u00e9rent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_26_36_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_36\" type=\"radio\" value=\"Par un autre \u00e9tablissement\" id=\"choice_26_36_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_36_1\" id=\"label_26_36_1\" class=\"gform-field-label gform-field-label--type-inline\">Par un autre \u00e9tablissement<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_26_36_2\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_36\" type=\"radio\" value=\"Par son assurance\" id=\"choice_26_36_2\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_36_2\" id=\"label_26_36_2\" class=\"gform-field-label gform-field-label--type-inline\">Par son assurance<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_26_36_3\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_36\" type=\"radio\" value=\"Par son ambassade\" id=\"choice_26_36_3\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_36_3\" id=\"label_26_36_3\" class=\"gform-field-label gform-field-label--type-inline\">Par son ambassade<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_26_36_4\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_36\" type=\"radio\" value=\"gf_other_choice\" id=\"choice_26_36_4\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_36_4\" id=\"label_26_36_4\" class=\"gform-field-label gform-field-label--type-inline\">Autre<\/label><br><input id=\"input_26_36_other\" class=\"gchoice_other_control\" name=\"input_36_other\" type=\"text\" value=\"Autre\" aria-label=\"Autre choix, veuillez sp\u00e9cifier\" disabled=\"disabled\">\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_13\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_13\"><label class=\"gfield_label gform-field-label\" for=\"input_26_13\">Quel est le probl\u00e8me qui am\u00e8ne le patient \u00e0 demander un rendez-vous \u00e0 l\u2019h\u00f4pital Foch&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_13\" id=\"input_26_13\" class=\"textarea medium\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_26_14\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_14\"><h3 class=\"gsection_title\">Condition m\u00e9dicale du patient<\/h3><\/div><div id=\"field_26_15\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_15\"><label class=\"gfield_label gform-field-label\" for=\"input_26_15\">Taille<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_number\"><input name=\"input_15\" id=\"input_26_15\" type=\"text\" step=\"any\" min=\"140\" max=\"220\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_26_15 gfield_description_26_15\"><div class=\"gfield_description instruction \" id=\"gfield_instruction_26_15\">Veuillez saisir un nombre entre <strong>140<\/strong> et <strong>220<\/strong>.<\/div><\/div><div class=\"gfield_description\" id=\"gfield_description_26_15\">en cm<\/div><\/div><div id=\"field_26_16\" class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_16\"><label class=\"gfield_label gform-field-label\" for=\"input_26_16\">Poids<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_number\"><input name=\"input_16\" id=\"input_26_16\" type=\"text\" step=\"any\" min=\"40\" max=\"200\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_26_16 gfield_description_26_16\"><div class=\"gfield_description instruction \" id=\"gfield_instruction_26_16\">Veuillez saisir un nombre entre <strong>40<\/strong> et <strong>200<\/strong>.<\/div><\/div><div class=\"gfield_description\" id=\"gfield_description_26_16\">en kg<\/div><\/div><div id=\"field_26_17\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_17\"><label class=\"gfield_label gform-field-label\" for=\"input_26_17\">Quelle(s) partie(s) du corps du patient est (sont) affect\u00e9e(s)? Merci de bien vouloir d\u00e9tailler les sympt\u00f4mes associ\u00e9s&nbsp;:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_17\" id=\"input_26_17\" class=\"textarea medium\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_26_18\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_18\"><label class=\"gfield_label gform-field-label\" for=\"input_26_18\">Depuis combien de temps le patient souffre-t-il de ce probl\u00e8me&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_text\"><input name=\"input_18\" id=\"input_26_18\" type=\"text\" value class=\"large\" aria-required=\"true\" aria-invalid=\"false\"> <\/div><\/div><div id=\"field_26_20\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_20\"><label class=\"gfield_label gform-field-label\" for=\"input_26_20\">Quel est le stade d\u2019\u00e9volution de ce probl\u00e8me aujourd\u2019hui&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_20\" id=\"input_26_20\" class=\"textarea small\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_26_23\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_23\"><h3 class=\"gsection_title\">M\u00e9dicaments<\/h3><\/div><div id=\"field_26_24\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_24\"><label class=\"gfield_label gform-field-label\" for=\"input_26_24\">Quels traitements le patient a\u2011t-il d\u00e9j\u00e0 essay\u00e9s et quels ont \u00e9t\u00e9 les r\u00e9sultats&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_24\" id=\"input_26_24\" class=\"textarea medium\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_26_25\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_25\"><label class=\"gfield_label gform-field-label\" for=\"input_26_25\">Merci de bien vouloir indiquer les m\u00e9dicaments que le patient prend actuellement&nbsp;:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_25\" id=\"input_26_25\" class=\"textarea small\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_26_37\" class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_37\"><label class=\"gfield_label gform-field-label\" for=\"input_26_37\">Le patient est allergique aux m\u00e9dicaments suivants&nbsp;:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_container_textarea\"><textarea name=\"input_37\" id=\"input_26_37\" class=\"textarea small\" aria-required=\"true\" aria-invalid=\"false\" rows=\"10\" cols=\"50\"><\/textarea><\/div><\/div><div id=\"field_26_28\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_28\"><h3 class=\"gsection_title\">Hygi\u00e8ne de vie du patient<\/h3><\/div><fieldset id=\"field_26_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_27\"><legend class=\"gfield_label gform-field-label\">Le patient fume-t-il&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_26_27\">\n\t\t\t<div class=\"gchoice gchoice_26_27_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_27\" type=\"radio\" value=\"Oui\" id=\"choice_26_27_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_27_0\" id=\"label_26_27_0\" class=\"gform-field-label gform-field-label--type-inline\">Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_26_27_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_27\" type=\"radio\" value=\"Non\" id=\"choice_26_27_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_27_1\" id=\"label_26_27_1\" class=\"gform-field-label gform-field-label--type-inline\">Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_26_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_29\"><legend class=\"gfield_label gform-field-label\">Le patient consomme-t-il de l\u2019alcool&nbsp;?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_26_29\">\n\t\t\t<div class=\"gchoice gchoice_26_29_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_29\" type=\"radio\" value=\"Oui\" id=\"choice_26_29_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_29_0\" id=\"label_26_29_0\" class=\"gform-field-label gform-field-label--type-inline\">Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_26_29_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_29\" type=\"radio\" value=\"Non\" id=\"choice_26_29_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_29_1\" id=\"label_26_29_1\" class=\"gform-field-label gform-field-label--type-inline\">Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_31\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_31\"><h3 class=\"gsection_title\">Validation du formulaire<\/h3><\/div><fieldset id=\"field_26_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_30\"><legend class=\"gfield_label gform-field-label\">Le questionnaire a \u00e9t\u00e9 rempli par&nbsp;:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_radio\"><div class=\"gfield_radio\" id=\"input_26_30\">\n\t\t\t<div class=\"gchoice gchoice_26_30_0\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_30\" type=\"radio\" value=\"Le patient\" id=\"choice_26_30_0\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_30_0\" id=\"label_26_30_0\" class=\"gform-field-label gform-field-label--type-inline\">Le patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class=\"gchoice gchoice_26_30_1\">\n\t\t\t\t\t<input class=\"gfield-choice-input\" name=\"input_30\" type=\"radio\" value=\"Une personne tierce\" id=\"choice_26_30_1\" onchange=\"gformToggleRadioOther( this )\">\n\t\t\t\t\t<label for=\"choice_26_30_1\" id=\"label_26_30_1\" class=\"gform-field-label gform-field-label--type-inline\">Une personne tierce<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_26_34\" class=\"gfield gfield--type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\" data-js-reload=\"field_26_34\"><label class=\"gfield_label gform-field-label\" for=\"input_26_34\">Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"gfield_signature_ui_container gform-theme__no-reset--children\"><div id=\"input_26_34_Container\" class=\"gfield_signature_container ginput_container\" style=\"height:180px; width:300px; \"><input type=\"hidden\" class=\"gform_hidden\" name=\"input_26_34_valid\" id=\"input_26_34_valid\"><canvas id=\"input_26_34\" width=\"300\" height=\"180\"><\/canvas><div class=\"gfield_signature_reset_container\"><svg id=\"input_26_34_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\" \/>\n\t\t\t\t<\/svg><svg id=\"input_26_34_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. 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