{"id":106,"date":"2021-07-15T21:22:56","date_gmt":"2021-07-16T01:22:56","guid":{"rendered":"https:\/\/echopaincanada.ca\/?page_id=106"},"modified":"2022-08-29T20:03:32","modified_gmt":"2022-08-30T00:03:32","slug":"register","status":"publish","type":"page","link":"https:\/\/echopaincanada.ca\/fr\/register\/","title":{"rendered":"Enregistrer"},"content":{"rendered":"\n<div style=\"height:20px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<div class=\"wp-block-uagb-call-to-action uagb-cta__outer-wrap uagb-block-5b5fdbf2\"><div class=\"uagb-cta__content-wrap uagb-cta__block uagb-cta__icon-position-right uagb-cta__content-right uagb-cta__content-stacked-tablet uagb-cta__button-valign-middle \"><div class=\"uagb-cta__left-right-wrap\"><div class=\"uagb-cta__content\"><div class=\"uagb-cta__title-wrap\"><h2 class=\"uagb-cta__title\">A note about our hub sites<\/h2><\/div><div class=\"uagb-cta-text-wrap\"><p class=\"uagb-cta__desc\">If you are looking for our McGill University program registration please visit our McGill University registration page, otherwise, please proceed below<\/p><\/div><\/div><div class=\"uagb-cta__link-wrapper uagb-cta__block-link-style\"><div class=\"uagb-cta__button-wrapper\"><a href=\"https:\/\/echopaincanada.ca\/mcgill\/register\/\" class=\"uagb-cta__button-link-wrapper uagb-cta__block-link uagb-cta-typeof-button\" target=\"_self\" rel=\"noopener noreferrer\"><span class=\"uagb-cta__link-content-inner\"><span>McGill University Registration<\/span><\/span><\/a><\/div><\/div><\/div><\/div><\/div>\n\n\n\n<div style=\"height:40px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity is-style-dots\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Register<\/h2>\n\n\n<div class=\"wpforms-container wpforms-container-full wpforms-container-save-resume wpforms-block\" id=\"wpforms-105\"><form id=\"wpforms-form-105\" class=\"wpforms-validate wpforms-form\" data-formid=\"105\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/106\" data-token=\"212c6afb38a2f895ccae93b09b9fa074\" data-token-time=\"1776951090\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator connector\" data-indicator=\"connector\" data-indicator-color=\"#0170b9\" data-scroll=\"1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\" style=\"min-width:14.285714285714%;\" data-page=\"1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#0170b9\" data-page=\"1\">1<span class=\"wpforms-page-indicator-page-triangle\" style=\"border-top-color:#0170b9\"><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Introduction<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-2\" style=\"min-width:14.285714285714%;\" data-page=\"2\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"2\">2<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Important Information Before You Get Started<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-3\" style=\"min-width:14.285714285714%;\" data-page=\"3\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"3\">3<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Demographic Information<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-4\" style=\"min-width:14.285714285714%;\" data-page=\"4\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"4\">4<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Practice Characteristics<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-5\" style=\"min-width:14.285714285714%;\" data-page=\"5\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"5\">5<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Statement of Collaboration<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-6\" style=\"min-width:14.285714285714%;\" data-page=\"6\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"6\">6<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Case Presentation<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-7\" style=\"min-width:14.285714285714%;\" data-page=\"7\"><span class=\"wpforms-page-indicator-page-number\"  data-page=\"7\">7<span class=\"wpforms-page-indicator-page-triangle\" ><\/span><\/span><span class=\"wpforms-page-indicator-page-title\">Website Registration<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-105-field_7-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"7\"><\/div><div id=\"wpforms-105-field_9-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"9\"><div id=\"wpforms-105-field_9\"><p>Thank you for your interest in Project ECHO Canada and your practice. By completing this form, you consent for your information to be used to better inform and tailor our program to suit your needs. \r\n<br \/>\r\n<br \/>\r\nPlease allocate approximately 15 minutes to complete this form. \r\n<br \/>\r\n<br \/>\r\nIf you have any questions or troubles with our registration process, please contact us at info@echopaincanada.ca..  \r\n<\/p><\/div><\/div><div id=\"wpforms-105-field_6-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"6\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"105\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-105-field_10-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"10\"><div id=\"wpforms-105-field_10\"><html>\r\n<p>\r\nECHO will connect you with an inter-professional specialist team and other primary care providers from across your province\/region by videoconference. Each weekly session includes case-based discussions and a short didactic. \r\n<br \/>\r\n<br \/>\r\nThere is no charge to attend but we ask that you actively engage in the peer learning community by sharing case presentations and ideas with the group. \r\n<br \/>\r\n<br \/>\r\nParticipants are asked to:\r\n<br \/>\r\n\u2022\tAttend ECHO sessions (There are 10-12 curriculum topics. Please join as often as possible.)<br \/>\r\n\u2022\tPresent 1 case (All cases are de-identified.) <br \/>\r\n\u2022\tComplete 2 questionnaires (Pre-Questionnaire will be sent to you before you start and Post-Questionnaire is sent after attending 5 sessions.)\r\n<br \/>\r\n<br \/>\r\nECHO Canada Chronic Pain and Substance Use Disorder is fully funded by Health Canada. \r\n<\/p>\r\n<\/html><\/div><\/div><div id=\"wpforms-105-field_11-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"11\"><label class=\"wpforms-field-label\">I have reviewed the important information above  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_11\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_11_1\" name=\"wpforms[fields][11][]\" value=\"I agree\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_11_1\">I agree<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_12-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"12\"><label class=\"wpforms-field-label\">What kind of videoconferencing equipment will you be using to access for ECHO sessions?  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_12\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_12_4\" name=\"wpforms[fields][12]\" value=\"Desktop\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_12_4\">Desktop<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_12_5\" name=\"wpforms[fields][12]\" value=\"Laptop\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_12_5\">Laptop<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_12_6\" name=\"wpforms[fields][12]\" value=\"Tablet\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_12_6\">Tablet<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_12_7\" name=\"wpforms[fields][12]\" value=\"Smartphone (Android\/ iOS)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_12_7\">Smartphone (Android\/ iOS)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_12_8\" name=\"wpforms[fields][12]\" value=\"Unsure, please follow up with me\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_12_8\">Unsure, please follow up with me<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_13-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"13\"><div id=\"wpforms-105-field_13\"><p>ECHO uses ZOOM, a free videoconference platform. You may download it from www.zoom.us. You will need internet access, speakers, microphone (and a camera) OR a telephone. <\/p><\/div><\/div><div id=\"wpforms-105-field_14-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"14\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"105\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-105-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-105-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-105-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-105-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-105-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-105-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"email\" id=\"wpforms-105-field_3\" class=\"wpforms-field-required wpforms-field-email-primary\" name=\"wpforms[fields][3][primary]\" spellcheck=\"false\" required><label for=\"wpforms-105-field_3\" class=\"wpforms-field-sublabel after\">Email<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"email\" id=\"wpforms-105-field_3-secondary\" class=\"wpforms-field-email-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-105-field_3\" name=\"wpforms[fields][3][secondary]\" spellcheck=\"false\" required><label for=\"wpforms-105-field_3-secondary\" class=\"wpforms-field-sublabel after\">Confirm Email<\/label><\/div><\/div><div class=\"wpforms-field-description\">This email will be used to receive future correspondence to connect to sessions and access resources.<\/div><\/div><div id=\"wpforms-105-field_16-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_16\">Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-105-field_16\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][16]\" aria-label=\"Phone Number\" required><\/div><div id=\"wpforms-105-field_18-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_18\">What province do you reside in? <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-105-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required=\"required\"><option value=\"Alberta\"  class=\"choice-4 depth-1\"  >Alberta<\/option><option value=\"British Columbia\"  class=\"choice-5 depth-1\"  >British Columbia<\/option><option value=\"Manitoba\"  class=\"choice-6 depth-1\"  >Manitoba<\/option><option value=\"New Brunswick\"  class=\"choice-7 depth-1\"  >New Brunswick<\/option><option value=\"Newfoundland &amp; Labrador\"  class=\"choice-8 depth-1\"  >Newfoundland &amp; Labrador<\/option><option value=\"Northwest Territories\"  class=\"choice-9 depth-1\"  >Northwest Territories<\/option><option value=\"Nova Scotia\"  class=\"choice-10 depth-1\"  >Nova Scotia<\/option><option value=\"Nunavut\"  class=\"choice-11 depth-1\"  >Nunavut<\/option><option value=\"Ontario\"  class=\"choice-12 depth-1\"  >Ontario<\/option><option value=\"Prince Edward Island\"  class=\"choice-13 depth-1\"  >Prince Edward Island<\/option><option value=\"Quebec\"  class=\"choice-14 depth-1\"  >Quebec<\/option><option value=\"Saskatchewan\"  class=\"choice-15 depth-1\"  >Saskatchewan<\/option><option value=\"Yukon\"  class=\"choice-16 depth-1\"  >Yukon<\/option><\/select><\/div><div id=\"wpforms-105-field_19-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_19\">What is your profession? <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-105-field_19\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][19]\" required=\"required\"><option value=\"Administrator\"  class=\"choice-4 depth-1\"  >Administrator<\/option><option value=\"MD - Physician Pediatrician\"  class=\"choice-5 depth-1\"  >MD &#8211; Physician Pediatrician<\/option><option value=\"MD - Physician Family Physician\"  class=\"choice-6 depth-1\"  >MD &#8211; Physician Family Physician<\/option><option value=\"MD - Specialist\"  class=\"choice-7 depth-1\"  >MD &#8211; Specialist<\/option><option value=\"Physician Assistant\"  class=\"choice-8 depth-1\"  >Physician Assistant<\/option><option value=\"Nurse Practitioner\"  class=\"choice-9 depth-1\"  >Nurse Practitioner<\/option><option value=\"Registered Nurse\"  class=\"choice-10 depth-1\"  >Registered Nurse<\/option><option value=\"Pharmacist\"  class=\"choice-11 depth-1\"  >Pharmacist<\/option><option value=\"Psychologist\"  class=\"choice-12 depth-1\"  >Psychologist<\/option><option value=\"Social Worker\"  class=\"choice-13 depth-1\"  >Social Worker<\/option><option value=\"Occupational Therapist\"  class=\"choice-14 depth-1\"  >Occupational Therapist<\/option><option value=\"Physiotherapist \/ Physical Therapist\"  class=\"choice-15 depth-1\"  >Physiotherapist \/ Physical Therapist<\/option><option value=\"Kinesiologist\/Exercise Counsellor\"  class=\"choice-16 depth-1\"  >Kinesiologist\/Exercise Counsellor<\/option><option value=\"Dietician\"  class=\"choice-17 depth-1\"  >Dietician<\/option><option value=\"Health Coach \/ Navigator (Child Life Specialist; Cancer Coach)\"  class=\"choice-18 depth-1\"  >Health Coach \/ Navigator (Child Life Specialist; Cancer Coach)<\/option><option value=\"Other (please specify)\"  class=\"choice-19 depth-1\"  >Other (please specify)<\/option><\/select><\/div><div id=\"wpforms-105-field_20-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"20\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_20\">What is your profession? (Other &#8211; please specify) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" required><\/div><div id=\"wpforms-105-field_21-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_21\">How many years have you been in practice? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-105-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" step=\"any\" required><\/div><div id=\"wpforms-105-field_22-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_22\">What is your age group?  <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-105-field_22\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][22]\" required=\"required\"><option value=\"20-29\"  class=\"choice-4 depth-1\"  >20-29<\/option><option value=\"30-39\"  class=\"choice-5 depth-1\"  >30-39<\/option><option value=\"40-49\"  class=\"choice-6 depth-1\"  >40-49<\/option><option value=\"50-59\"  class=\"choice-7 depth-1\"  >50-59<\/option><option value=\"60-69\"  class=\"choice-8 depth-1\"  >60-69<\/option><option value=\"70-79\"  class=\"choice-9 depth-1\"  >70-79<\/option><option value=\"80+\"  class=\"choice-10 depth-1\"  >80+<\/option><\/select><\/div><div id=\"wpforms-105-field_23-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_23\">What is your current gender identity?  <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-105-field_23\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][23]\" required=\"required\"><option value=\"Male\"  class=\"choice-1 depth-1\"  >Male<\/option><option value=\"Female\"  class=\"choice-2 depth-1\"  >Female<\/option><option value=\"Prefer not to say\"  class=\"choice-3 depth-1\"  >Prefer not to say<\/option><option value=\"Other - please describe\"  class=\"choice-4 depth-1\"  >Other &#8211; please describe<\/option><\/select><\/div><div id=\"wpforms-105-field_24-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"24\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_24\">What is your current gender identity &#8211; Other (please describe) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_24\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/div><div id=\"wpforms-105-field_25-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"25\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"105\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-105-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_29\">Practice \/ Organization Name  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" required><\/div><div id=\"wpforms-105-field_17-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"17\"><label class=\"wpforms-field-label\">Practice Address <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-105-field_17\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][17][address1]\" required><label for=\"wpforms-105-field_17\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-105-field_17-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][17][address2]\" ><label for=\"wpforms-105-field_17-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-105-field_17-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][17][city]\" required><label for=\"wpforms-105-field_17-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-105-field_17-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][17][state]\" required><label for=\"wpforms-105-field_17-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-105-field_17-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][17][postal]\" required><label for=\"wpforms-105-field_17-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-105-field_17-country\" class=\"wpforms-field-address-country wpforms-field-required\" name=\"wpforms[fields][17][country]\" required><option class=\"placeholder\" value=\"\" selected disabled>Canada<\/option><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\" >South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-105-field_17-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/div><div id=\"wpforms-105-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_30\">1. Approximately how many patients are registered in your practice right now?  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_30\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][30]\" required><\/div><div id=\"wpforms-105-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_31\">2.\tApproximately what percentage of your patients would you describe as disadvantaged? (e.g. receiving social assistance such as ODSP) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_31\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][31]\" required><\/div><div id=\"wpforms-105-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_32\">3.\tWhat percentage of patients in your practice have chronic pain? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_32\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][32]\" required><\/div><div id=\"wpforms-105-field_38-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-trigger\" data-field-id=\"38\"><label class=\"wpforms-field-label\">4.\tWe are trying to gather a sense of what patient population you serve. Approximately what percentage of your practice would you describe as <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_38\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_4\" name=\"wpforms[fields][38][]\" value=\"Aboriginal\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_4\">Aboriginal\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_5\" name=\"wpforms[fields][38][]\" value=\"Ethnic minorities\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_5\">Ethnic minorities\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_6\" name=\"wpforms[fields][38][]\" value=\"Francophone\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_6\">Francophone\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_7\" name=\"wpforms[fields][38][]\" value=\"Refugee \t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_7\">Refugee \t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_8\" name=\"wpforms[fields][38][]\" value=\"Immigrants\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_8\">Immigrants\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_9\" name=\"wpforms[fields][38][]\" value=\"Prison inmates\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_9\">Prison inmates\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_10\" name=\"wpforms[fields][38][]\" value=\"Veterans\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_10\">Veterans\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_11\" name=\"wpforms[fields][38][]\" value=\"Group homes\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_11\">Group homes\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_12\" name=\"wpforms[fields][38][]\" value=\"Long-term care homes\t\u2026\u2026. (%)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_12\">Long-term care homes\t\u2026\u2026. (%)<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_38_13\" name=\"wpforms[fields][38][]\" value=\"Other?\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_38_13\">Other?<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_37-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_37\">Aboriginal % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_37\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][37]\" required><\/div><div id=\"wpforms-105-field_39-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_39\">Ethnic Minorities % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_39\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][39]\" required><\/div><div id=\"wpforms-105-field_40-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"40\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_40\">Francophone % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_40\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][40]\" required><\/div><div id=\"wpforms-105-field_41-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_41\">Refugee % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_41\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][41]\" required><\/div><div id=\"wpforms-105-field_42-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"42\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_42\">Immigrants % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_42\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][42]\" required><\/div><div id=\"wpforms-105-field_43-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_43\">Prison Inmates % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_43\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][43]\" required><\/div><div id=\"wpforms-105-field_44-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_44\">Veterans % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_44\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][44]\" required><\/div><div id=\"wpforms-105-field_45-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_45\">Group home % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_45\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][45]\" required><\/div><div id=\"wpforms-105-field_46-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_46\">Long Term Care Home % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_46\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][46]\" required><\/div><div id=\"wpforms-105-field_47-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_47\">Other population % <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_47\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][47]\" required><\/div><div id=\"wpforms-105-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_48\">5.\tHow many NEW patients with chronic pain would you be willing to accept in your practice over the next year? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_48\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][48]\" required><\/div><div id=\"wpforms-105-field_49-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_49\">6.\tIn the last 12 months, approximately how many referrals to a chronic pain specialist did you make? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_49\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][49]\" required><\/div><div id=\"wpforms-105-field_77-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_77\">7.\tIn the last 12 months, approximately how many referrals to multidisciplinary pain clinics did you make? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_77\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][77]\" required><\/div><div id=\"wpforms-105-field_50-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_50\">8.\tIn the last 12 months, approximately how long do your patients wait to be seen by these pain specialists? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_50\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][50]\" required><\/div><div id=\"wpforms-105-field_51-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_51\">9.\tHow many years have you been in practice? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_51\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][51]\" required><\/div><div id=\"wpforms-105-field_53-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"53\"><label class=\"wpforms-field-label\">10a.\tWhat practice model do you practice in? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_53\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_4\" name=\"wpforms[fields][53]\" value=\"Solo Practitioner\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_4\">Solo Practitioner<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_5\" name=\"wpforms[fields][53]\" value=\"Group Practice\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_5\">Group Practice<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_6\" name=\"wpforms[fields][53]\" value=\"Long-Term Care Facility\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_6\">Long-Term Care Facility<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_7\" name=\"wpforms[fields][53]\" value=\"Aboriginal Health Centre\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_7\">Aboriginal Health Centre<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_8\" name=\"wpforms[fields][53]\" value=\"Nurse Practitioner-Led Clinic\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_8\">Nurse Practitioner-Led Clinic<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_9\" name=\"wpforms[fields][53]\" value=\"Hospital: Emergency department, in-patient care, out-patient clinic\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_9\">Hospital: Emergency department, in-patient care, out-patient clinic<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_10\" name=\"wpforms[fields][53]\" value=\"Academic setting (University, college, etc.)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_10\">Academic setting (University, college, etc.)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_53_11\" name=\"wpforms[fields][53]\" value=\"Other, please specify:\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_53_11\">Other, please specify:<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_55-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"55\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_55\">10a. Other, please specify <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_55\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][55]\" required><\/div><div id=\"wpforms-105-field_54-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"54\"><label class=\"wpforms-field-label\">10b.\tIf applicable, please indicate your secondary practice * (If more than one, please elaborate under &quot;Other&quot;) <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_54\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_4\" name=\"wpforms[fields][54]\" value=\"Solo Practitioner\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_4\">Solo Practitioner<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_5\" name=\"wpforms[fields][54]\" value=\"Group Practice\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_5\">Group Practice<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_6\" name=\"wpforms[fields][54]\" value=\"Long-Term Care Facility\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_6\">Long-Term Care Facility<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_7\" name=\"wpforms[fields][54]\" value=\"Aboriginal Health Centre\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_7\">Aboriginal Health Centre<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_8\" name=\"wpforms[fields][54]\" value=\"Nurse Practitioner-Led Clinic\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_8\">Nurse Practitioner-Led Clinic<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_9\" name=\"wpforms[fields][54]\" value=\"Hospital: Emergency department, in-patient care, out-patient clinic\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_9\">Hospital: Emergency department, in-patient care, out-patient clinic<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_10\" name=\"wpforms[fields][54]\" value=\"Academic setting (University, college, etc.)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_10\">Academic setting (University, college, etc.)<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_11\" name=\"wpforms[fields][54]\" value=\"Other, please specify:\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_11\">Other, please specify:<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_54_12\" name=\"wpforms[fields][54]\" value=\"Not applicable\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_54_12\">Not applicable<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_56-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"56\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_56\">10b. Other, please specify <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_56\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][56]\" required><\/div><div id=\"wpforms-105-field_57-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"57\"><label class=\"wpforms-field-label\">11.\tWhat type of environment  do you practice in? (Select all that apply. If more than one, please elaborate under &quot;Other&quot;) * <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_57\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_57_4\" name=\"wpforms[fields][57]\" value=\"Remote (defined as areas without year-round road access, or which rely on a third party such as an airplane or ferry for transportation to a larger centre)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_57_4\">Remote (defined as areas without year-round road access, or which rely on a third party such as an airplane or ferry for transportation to a larger centre)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_57_5\" name=\"wpforms[fields][57]\" value=\"Rural (defined as areas with a population of less than 30,000 that are more than 30 minutes away from a community with a population of more than 30,000)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_57_5\">Rural (defined as areas with a population of less than 30,000 that are more than 30 minutes away from a community with a population of more than 30,000)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_57_6\" name=\"wpforms[fields][57]\" value=\"Suburban\/Urban (defined as areas with populations over 30,000)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_57_6\">Suburban\/Urban (defined as areas with populations over 30,000)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_57_7\" name=\"wpforms[fields][57]\" value=\"Other (please specify below)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_57_7\">Other (please specify below)<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"58\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_58\">What type of environment  (Other) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_58\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][58]\" required><\/div><div id=\"wpforms-105-field_59-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"59\"><label class=\"wpforms-field-label\">12.\tIn which country did you complete your professional training? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_59\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_59_1\" name=\"wpforms[fields][59]\" value=\"Canada\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_59_1\">Canada<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_59_2\" name=\"wpforms[fields][59]\" value=\"Outside of Canada\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_59_2\">Outside of Canada<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_59_3\" name=\"wpforms[fields][59]\" value=\"Other (please specify)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_59_3\">Other (please specify)<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_60-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"60\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_60\">Professional Training (Other) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_60\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][60]\" required><\/div><div id=\"wpforms-105-field_61-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_61\">13a. About how much training did you have in chronic pain management during your professional training (e.g. Pharmacy School) ? (hours\/days\/months) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_61\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][61]\" required><\/div><div id=\"wpforms-105-field_62-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_62\">13b. About how much training did you have in chronic pain management during your post-graduate training (e.g. Residency, Practicum) ? (hours)  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_62\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][62]\" required><\/div><div id=\"wpforms-105-field_63-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_63\">13c. About how much training did you have in chronic pain management after graduation (e.g. CME, CPD events, etc.) ? (hours\/days\/months) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_63\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][63]\" required><\/div><div id=\"wpforms-105-field_64-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"64\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_64\">14.\tApproximately how many patients do you have in your practice right now?  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_64\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][64]\" required><\/div><div id=\"wpforms-105-field_65-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"65\" style=\"display:none;\"><label class=\"wpforms-field-label\">15.\tHow did you hear about ECHO?  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_65\" class=\"wpforms-field-required\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_4\" name=\"wpforms[fields][65][]\" value=\"Conference\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_4\">Conference<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_5\" name=\"wpforms[fields][65][]\" value=\"Presentation\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_5\">Presentation<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_6\" name=\"wpforms[fields][65][]\" value=\"Colleague\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_6\">Colleague<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_7\" name=\"wpforms[fields][65][]\" value=\"An ECHO staff\/team member\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_7\">An ECHO staff\/team member<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_8\" name=\"wpforms[fields][65][]\" value=\"An email\/article\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_8\">An email\/article<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_9\" name=\"wpforms[fields][65][]\" value=\"Your LHIN\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_9\">Your LHIN<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_10\" name=\"wpforms[fields][65][]\" value=\"An ECHO participant\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_10\">An ECHO participant<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_11\" name=\"wpforms[fields][65][]\" value=\"A colleague\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_11\">A colleague<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_12\" name=\"wpforms[fields][65][]\" value=\"Internet\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_12\">Internet<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_65_13\" name=\"wpforms[fields][65][]\" value=\"Other: (please specify)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_65_13\">Other: (please specify)<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_66-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"66\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_66\">How did you hear about ECHO (Other, please specify) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_66\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][66]\" required><\/div><div id=\"wpforms-105-field_26-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"26\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"4\" data-formid=\"105\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-105-field_67-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"67\"><div id=\"wpforms-105-field_67\"><p>Please note that there are certain conditions which must be agreed to if you are selected to participate in this ECHO UHN program. Please indicate if you agree with the following statements (all must be agreed to):\r\n<br \/>\r\n<br \/>\r\n\u2022\t<b>Patient Relationship Disclaimer:<\/b> ECHO case presentations do not create or establish provider-patient client relationship between any ECHO Hub Clinician and a patient whose case is presented.<br \/>\r\n\u2022\t<b>Commitment to Collaboration:<\/b> Recommendations \r\nfrom the Hub do not in any way replace my own diligence and professional expertise with respect to my patients or clients. University Health Network and its officers, directors, employees, subcontractors and agents accept no responsibility or liability for any treatment decisions I make as a result of my participation, or association with ECHO UHN. I agree to be solely responsible for the treatment of my patients and understand that all clinical decisions rest with me regardless of recommendations provided by the expert hub team and other ECHO participants.<br \/>\r\n\u2022\t<b>De-identified Information Notice and Confidentiality:<\/b> Personal identifying information is not to be shared during ECHO sessions. If this does occur, I&#8217;ll follow my own organization&#8217;s policies and procedures to address the privacy breach.<br \/>\r\n\u2022\t<b>Participation Notice: <\/b>I and\/or my organization (Spoke) will participate in as many sessions as possible during the curriculum to maximize my learning experience. I understand that case discussions are part of every session and that I, or a member of my team, will be expected to present at least 1 (one) de-identified patient case. <br \/>\r\n\u2022\t<b>Recording, Photographs, and Guests: <\/b>The ECHO team records sessions for educational purposes and occasionally takes photos for promotional purposes. I give permission for my photos to be used unless explicitly requested in writing. \r\n<br \/>\r\n<br \/>\r\n<br \/>\r\n<b>Data Use Notice<\/b>: I understand that the following data will be collected for reporting purposes: \r\n<br \/>\r\n<br \/>\r\n1. In order to meet Health Canada funding deliverables, ECHO Pain Canada at UHN and {insert hub site name} collects participant data for annual reports that are submitted directly to Health Canada. Participant data will always be anonymized. \r\n<br \/>\r\n2. In order to support quality improvement and quality assurance, the ECHO Pain Canada at UHN collects participation data for each participating ECHO site. This data allows ECHO Pain Canada at UHN to measure, analyze, and report on the model\u2019s reach within each province. Your anonymized, aggregate data will be used in reports for quality improvement and quality assurance purposes. \r\n<br \/>\r\n<br \/>\r\n<\/p>\r\n<\/div><\/div><div id=\"wpforms-105-field_68-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"68\"><label class=\"wpforms-field-label\">Statement of Collaboration <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_68\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-105-field_68_1\" name=\"wpforms[fields][68][]\" value=\"I agree to these terms of collaboration.\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_68_1\">I agree to these terms of collaboration.<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_69-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_69\">Signature <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-105-field_69\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][69]\" autocomplete=\"off\" inputmode=\"none\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-105-field_69-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 768t103-385.5T382.5 103T768 0t385.5 103T1433 382.5T1536 768z\"\/>\n\t\t\t\t<\/svg>\n\t\t\t\t<div class=\"wpforms-signature-clear-caption\">Clear Signature<\/div>\n\t\t\t<\/div><\/div><\/div><div id=\"wpforms-105-field_70-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_70\">Date <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-105-field_70\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][70][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-105-field_27-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"27\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"5\" data-formid=\"105\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" data-page=\"6\" style=\"display:none;\"><div id=\"wpforms-105-field_71-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"71\"><div id=\"wpforms-105-field_71\"><p>\r\nCase Presentations are an integral part of ECHO sessions. There is no limit to the number of cases you can present, however we ask that all participants present at least 1 case. \r\n<br \/>\r\n<br \/>\r\n\u2022\tAll cases are de-identified\r\n<br \/>\r\n\u2022\tThere is no patient doctor relationship established between the ECHO specialist team and your patient. <br \/>\r\n\u2022\tCase presentations are mostly pre-scheduled, however you can reach out whenever you have case questions to schedule a more \u2018spontaneous case\u2019.<br \/>\r\n\u2022\tAlthough most participants discuss their own patient cases, others present cases on behalf of their team. <br \/>\r\n<br \/>\r\n<\/p><\/div><\/div><div id=\"wpforms-105-field_72-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"72\"><label class=\"wpforms-field-label\">Please select an option  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-105-field_72\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_72_1\" name=\"wpforms[fields][72]\" value=\"Unsure\/I have questions. Please follow up with me to schedule the case. \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_72_1\">Unsure\/I have questions. Please follow up with me to schedule the case.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-105-field_72_2\" name=\"wpforms[fields][72]\" value=\"I have selected my case dates, below\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-105-field_72_2\">I have selected my case dates, below<\/label><\/li><\/ul><\/div><div id=\"wpforms-105-field_73-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_73\">Potential Presentation Date  <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-105-field_73\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][73][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-105-field_74-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"74\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-105-field_74\">Potential Presentation Date (Second choice) <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-105-field_74\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][74][date]\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-105-field_28-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"28\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"6\" data-formid=\"105\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7 last \" data-page=\"7\" style=\"display:none;\"><div id=\"wpforms-105-field_75-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"75\"><div id=\"wpforms-105-field_75\"><p>\r\nProject ECHO at UHN utilizes web-based resources to efficiently distribute materials. These materials include access to the discussion board, archive, didactic presentations, videos, events and more. Please fill in the following fields to create your username and password for the website, and your email address indicated earlier will be used to create your account. \r\n\r\n<\/p><\/div><\/div><div id=\"wpforms-105-field_4-container\" class=\"wpforms-field wpforms-field-password\" data-field-id=\"4\"><label class=\"wpforms-field-label\">Password <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"password\" id=\"wpforms-105-field_4\" class=\"wpforms-field-required wpforms-field-password-primary\" data-rule-password-strength=\"1\" data-password-strength-level=\"3\" name=\"wpforms[fields][4][primary]\" spellcheck=\"false\" required><label for=\"wpforms-105-field_4\" class=\"wpforms-field-sublabel after\">Password<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"password\" id=\"wpforms-105-field_4-secondary\" class=\"wpforms-field-password-secondary wpforms-field-required\" data-rule-confirm=\"#wpforms-105-field_4\" name=\"wpforms[fields][4][secondary]\" spellcheck=\"false\" required><label for=\"wpforms-105-field_4-secondary\" class=\"wpforms-field-sublabel after\">Confirm Password<\/label><\/div><\/div><\/div><div id=\"wpforms-105-field_76-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"76\"><div id=\"wpforms-105-field_76\"><p style=\"font-size:16px\">What happens next?<\/p>\r\n<br \/>\r\n<p>You will receive an email shortly with the following: <br \/>\r\nConfirmation of your start date and case date <br \/>\r\nThe ECHO Pre Impact questionnaire <br \/>\r\nCase Presentation Form <br \/>\r\nYour ECHO website login information <br \/>\r\n<br \/>\r\nYou will receive the weekly ECHO e-agenda on the day prior to your start date <br \/>\r\nThe e-agenda has the Link to join ECHO session. <br \/><br \/>\r\n<\/p>\r\n<\/div><\/div><div id=\"wpforms-105-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"105\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/echopaincanada.ca\/fr\/wp-json\/wp\/v2\/pages\/106\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-105\" class=\"wpforms-submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\n\n<div style=\"height:20px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Enregistrer<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_uag_custom_page_level_css":"","site-sidebar-layout":"default","site-content-layout":"default","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"default","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center 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