{"id":21384,"date":"2026-06-12T09:37:38","date_gmt":"2026-06-12T09:37:38","guid":{"rendered":"https:\/\/apollo.clioweb.dev\/demande-de-reservation-pour-le-personnel\/"},"modified":"2026-07-09T11:07:48","modified_gmt":"2026-07-09T11:07:48","slug":"demande-de-reservation-pour-le-personnel","status":"publish","type":"page","link":"https:\/\/apollo.clioweb.dev\/fr\/demande-de-reservation-pour-le-personnel\/","title":{"rendered":"Demande de r\u00e9servation pour le personnel"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"21384\" class=\"elementor elementor-21384 elementor-20537\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a9da9a3 e-flex e-con-boxed e-con e-parent\" data-id=\"a9da9a3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-d92baa3 e-con-full e-flex e-con e-child\" data-id=\"d92baa3\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b36b6cf elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"b36b6cf\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Formulaire de demande de r\u00e9servation d\u2019Apollo Cannabis Clinics\n<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-06114c5 elementor-widget__width-initial elementor-widget-mobile__width-inherit elementor-widget elementor-widget-text-editor\" data-id=\"06114c5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<div class=\"wpb_text_column wpb_content_element \"><div class=\"wpb_wrapper\"><p>Remplissez ce formulaire si vous souhaitez prendre rendez-vous avec Apollo Cannabis Clinics et r\u00e9clamer du cannabis m\u00e9dical au titre de votre compte de d\u00e9penses de sant\u00e9 (CDS) ou de votre r\u00e9gime d\u2019assurance collective chez <b><u>Manuvie.<\/u><\/b> Une fois ce formulaire rempli, vous serez contact\u00e9 pour fixer un rendez-vous afin de parler avec un professionnel de la sant\u00e9 chez Apollo.<\/p><\/div><\/div><div id=\"gform_wrapper_39\" class=\"gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework\" data-form-theme=\"gravity-theme\" data-form-index=\"0\"><form id=\"gform_39\" action=\"https:\/\/apollocannabis.ca\/staff-booking-request\/\" enctype=\"multipart\/form-data\" method=\"post\" novalidate=\"\" data-formid=\"39\"><div class=\"gform-body gform_body\"><div id=\"gform_fields_39\" class=\"gform_fields top_label form_sublabel_below description_below validation_below\"> <\/div><\/div><\/form><\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-19c68b3 e-flex e-con-boxed e-con e-parent\" data-id=\"19c68b3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-1c5f257 e-con-full e-flex e-con e-child\" data-id=\"1c5f257\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5acd784 elementor-widget elementor-widget-shortcode\" data-id=\"5acd784\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\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 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Staff Appt Request Form<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_34'  action='\/fr\/wp-json\/wp\/v2\/pages\/21384' data-formid='34' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_34' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_34_6\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently a patient of Apollo Cannabis Clinics?<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_34_6'>\n\t\t\t<div class='gchoice gchoice_34_6_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='Yes'  id='choice_34_6_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_6_0' id='label_34_6_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_6_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_6' type='radio' value='No'  id='choice_34_6_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_6_1' id='label_34_6_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_34_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name (As shown on your healthcard)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_34_1'>\n                            \n                            <span id='input_34_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_34_1_3' value=''   aria-required='true'   placeholder='Patient&#039;s First Name'  \/>\n                                                    <label for='input_34_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_34_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_34_1_6' value=''   aria-required='true'   placeholder='Patient&#039;s Last Name'  \/>\n                                                    <label for='input_34_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_34_7\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_34_7'>Preferred First Name?<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_34_7' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_8\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_34_8'>Health Card Number (REQUIRED if you reside in ON, AB, QC, or BC)<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_34_8' type='text' value='' class='large'    placeholder='Health Card Number \/ Provincial Health Insurance'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_9\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_34_9'>Health Card Version Code (2 letter version code - ON Only!)<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_34_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_10\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_34_10'>Health Card Expiry Date (REQUIRED if you reside in ON, QC, or BC)<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_34_10' type='text' value='' class='large'    placeholder='(mm\/dd\/yyyy)'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_11\" class=\"gfield gfield--type-text gfield--width-full 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_34_11'>Date of Birth<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_34_11' type='text' value='' class='large'    placeholder='(mm\/dd\/yyyy)' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_4\" class=\"gfield gfield--type-email gfield--width-full 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_34_4'>Email<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_4' id='input_34_4' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_34_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consent with Apollo Clinics communicating with you by email?<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_34_12'>\n\t\t\t<div class='gchoice gchoice_34_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Yes'  id='choice_34_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_12_0' id='label_34_12_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='No'  id='choice_34_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_12_1' id='label_34_12_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_34_3\" class=\"gfield gfield--type-phone 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_34_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_34_3' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_34_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is this a home or mobile phone number?<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_34_13'>\n\t\t\t<div class='gchoice gchoice_34_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Home phone'  id='choice_34_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_13_0' id='label_34_13_0' class='gform-field-label gform-field-label--type-inline'>Home phone<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Mobile Phone'  id='choice_34_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_13_1' id='label_34_13_1' class='gform-field-label gform-field-label--type-inline'>Mobile Phone<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_34_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Best Time to Call?<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_34_23'>\n\t\t\t<div class='gchoice gchoice_34_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='AM'  id='choice_34_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_23_0' id='label_34_23_0' class='gform-field-label gform-field-label--type-inline'>AM<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='PM'  id='choice_34_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_23_1' id='label_34_23_1' class='gform-field-label gform-field-label--type-inline'>PM<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_34_14\" class=\"gfield gfield--type-text gfield--width-full 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_34_14'>Residential Mailing Address<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_34_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_15\" class=\"gfield gfield--type-text gfield--width-full 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_34_15'>City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_34_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_16\" class=\"gfield gfield--type-text gfield--width-full 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_34_16'>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_16' id='input_34_16' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_17\" class=\"gfield gfield--type-text gfield--width-full 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_34_17'>Postal Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_34_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_34_18\" class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_34_18'>If you want your medical cannabis shipped to a PO Box or Flex Address instead of your residential address (Canada Post only) please provide the information below.<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_34_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_34_18\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_34_18'>Ensure you carefully review the address information before submitting this form. <\/div><\/div><fieldset id=\"field_34_19\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you a veteran of the Canadian Armed Forces?<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_34_19'>\n\t\t\t<div class='gchoice gchoice_34_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_34_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_19_0' id='label_34_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_34_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_19_1' id='label_34_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_34_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been in a Motor Vehicle Accident (MVA) AND currently have an open claim?<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_34_20'>\n\t\t\t<div class='gchoice gchoice_34_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_34_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_20_0' id='label_34_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_34_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_20_1' id='label_34_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_34_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been diagnosed with schizophrenia, bipolar disorder or another mood disorder?<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_34_21'>\n\t\t\t<div class='gchoice gchoice_34_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_34_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_21_0' id='label_34_21_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Bipolar'  id='choice_34_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_21_1' id='label_34_21_1' class='gform-field-label gform-field-label--type-inline'>Bipolar<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_21_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Schizophrenia'  id='choice_34_21_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_21_2' id='label_34_21_2' class='gform-field-label gform-field-label--type-inline'>Schizophrenia<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_21_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='gf_other_choice'  id='choice_34_21_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_21_3' id='label_34_21_3' class='gform-field-label gform-field-label--type-inline'>Autre<\/label><br \/><input id='input_34_21_other' class='gchoice_other_control' name='input_21_other' type='text' value='Autre' aria-label='Autre choix, veuillez sp\u00e9cifier'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_34_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Will you be claiming medical cannabis using your drug benefit coverage or will you use your Health Care Spending Account?<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_34_22'>\n\t\t\t<div class='gchoice gchoice_34_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Drug Benefit Coverage'  id='choice_34_22_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_34_22\"   \/>\n\t\t\t\t\t<label for='choice_34_22_0' id='label_34_22_0' class='gform-field-label gform-field-label--type-inline'>Drug Benefit Coverage<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_34_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Healthcare Spending Account'  id='choice_34_22_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_34_22_1' id='label_34_22_1' class='gform-field-label gform-field-label--type-inline'>Healthcare Spending Account<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_34_22'>Note: If you are going to claim medical cannabis under your drug benefit coverage Apollo Clinics will send you a copy of your medical document\/prescription which is required for Manulife to process your claim. 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