Formulaire d\u2019admission du patient – Summit Health<\/title>\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n <link href=\"https:\/\/cdn.jsdelivr.net\/npm\/bootstrap@5.0.1\/dist\/css\/bootstrap.min.css\" rel=\"stylesheet\">\n <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/signature_pad@4.1.5\/dist\/signature_pad.umd.min.js\"><\/script>\n <script src=\"https:\/\/ajax.googleapis.com\/ajax\/libs\/jquery\/3.6.0\/jquery.min.js\"><\/script>\n <script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/html2pdf.js\/0.10.1\/html2pdf.bundle.min.js\"><\/script>\n <style>\n html, body {\n margin: 0;\n padding: 0;\n background: #fff;\n }\n * {\n box-sizing: border-box;\n }\n body {\n padding: 20px;\n font-family: sans-serif;\n font-size: 14px;\n }\n #signature-pad {\n border: 1px solid #ccc;\n width: 100%;\n max-width: 600px;\n height: 200px;\n }\n canvas {\n touch-action: none;\n display: block;\n }\n <\/style>\n<\/head>\n<body>\n\n<div id=\"pdf-wrapper\" style=\"background-color: #fff; color: #000; padding: 20px; margin: 0 auto; max-width: 800px; min-height: 100vh; box-sizing: border-box;\">\n <h2 class=\"mb-4\">Formulaire d\u2019admission du patient – Summit Health<\/h2>\n\n <div class=\"mb-3\">\n <label for=\"patientName\" class=\"form-label\"><strong>Nom complet du patient<\/strong><\/label>\n <input type=\"text\" class=\"form-control\" id=\"patientName\" placeholder=\"Entrez le nom complet\">\n <\/div>\n\n <div class=\"mb-3\">\n <label for=\"dischargeDate\" class=\"form-label\"><strong>Date<\/strong><\/label>\n <input type=\"date\" class=\"form-control\" id=\"dischargeDate\">\n <\/div>\n\n <div id=\"intakeSection\" style=\"display: block;\">\n <p><strong>Reconnaissances \u00e0 l\u2019admission<\/strong><\/p>\n <ul>\n <li>Je donne par la pr\u00e9sente mon consentement \u00e9clair\u00e9 pour recevoir une perfusion intraveineuse chez Summit Health, apr\u00e8s avoir eu l\u2019opportunit\u00e9 de poser des questions concernant la nature, les risques, les b\u00e9n\u00e9fices et les alternatives au traitement propos\u00e9. Je comprends que je peux retirer ce consentement \u00e0 tout moment avant ou pendant la proc\u00e9dure.<\/li>\n <li>Je reconnais et accepte la politique d\u2019annulation de Summit Health, qui stipule que les annulations faites dans les 48 heures pr\u00e9c\u00e9dant l\u2019heure pr\u00e9vue du rendez-vous, ou le fait de ne pas se pr\u00e9senter au rendez-vous, peuvent entra\u00eener des frais non remboursables de 60 $. Je comprends que cette politique vise \u00e0 assurer un acc\u00e8s rapide pour les autres patients.<\/li>\n <li>Si je fournis mon propre m\u00e9dicament pour la perfusion, je d\u00e9clare que le produit a \u00e9t\u00e9 stock\u00e9 et transport\u00e9 conform\u00e9ment aux directives pharmaceutiques, y compris le maintien de la cha\u00eene du froid lorsque requis. J\u2019accepte l\u2019enti\u00e8re responsabilit\u00e9 l\u00e9gale de l\u2019int\u00e9grit\u00e9 du m\u00e9dicament et d\u00e9gage Summit Health de toute responsabilit\u00e9 li\u00e9e \u00e0 une mauvaise manipulation ou aux effets ind\u00e9sirables caus\u00e9s par l\u2019\u00e9tat du produit.<\/li>\n <li>Si je re\u00e7ois de la Benadryl (diphenhydramine) ou tout autre m\u00e9dicament s\u00e9datif dans le cadre de mon traitement, je reconnais avoir \u00e9t\u00e9 inform\u00e9 de ne pas conduire, manipuler des machines lourdes ou effectuer toute activit\u00e9 n\u00e9cessitant une vigilance mentale pendant au moins 8 heures apr\u00e8s l\u2019administration. J\u2019accepte toute responsabilit\u00e9 l\u00e9gale pour les cons\u00e9quences de la non-observation de ce conseil.<\/li>\n <\/ul>\n <\/div>\n\n <div id=\"dischargeSection\" style=\"display: none;\">\n <p><strong>Reconnaissance de sortie<\/strong><\/p>\n <ul>\n <li>Je reconnais avoir choisi de quitter la clinique avant la fin de la p\u00e9riode de surveillance post-perfusion recommand\u00e9e de 60 minutes. Je comprends les risques potentiels associ\u00e9s et d\u00e9gage Summit Health de toute responsabilit\u00e9 en cas de r\u00e9action ou complication retard\u00e9e apr\u00e8s mon d\u00e9part.<\/li>\n <\/ul>\n <\/div>\n\n <div class=\"form-check mb-3\">\n <input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"consentCheckbox\">\n <label class=\"form-check-label\" for=\"consentCheckbox\">\n Je confirme avoir lu et compris les informations ci-dessus et j\u2019accepte les termes et conditions.\n <\/label>\n <\/div>\n\n <div class=\"mb-3\">\n <label class=\"form-label\"><strong>Signature<\/strong><\/label><br>\n <canvas id=\"signature-pad\"><\/canvas><br>\n <button class=\"btn btn-secondary mt-2\" id=\"clearSignature\">Effacer la signature<\/button>\n <\/div>\n\n <div id=\"signatureMetadata\" class=\"mb-3\" style=\"font-size: 12px; color: #555;\"><\/div>\n\n <button class=\"btn btn-primary\" id=\"submitForm\">Soumettre le formulaire<\/button>\n\n <div class=\"alert alert-success mt-3\" style=\"display: none;\" id=\"successMessage\">\n Le formulaire de consentement a \u00e9t\u00e9 soumis avec succ\u00e8s.\n <\/div>\n <div class=\"alert alert-danger mt-3\" style=\"display: none;\" id=\"errorMessage\">\n Une erreur s’est produite lors de la soumission du formulaire. Veuillez en informer votre infirmier(\u00e8re).\n <\/div>\n<\/div>\n\n<script>\n const urlParams = new URLSearchParams(window.location.search);\n const relatedObjectId = urlParams.get(\"relatedObjectId\");\n\n if (!relatedObjectId) {\n document.getElementById(\"pdf-wrapper\").innerHTML = '<div class=\"alert alert-danger\">Ce formulaire contient une erreur technique. Veuillez parler \u00e0 votre infirmier(\u00e8re) pour le compl\u00e9ter.<\/div>';\n throw new Error(\"Missing relatedObjectId in URL.\");\n }\n\n const canvas = document.getElementById(\"signature-pad\");\n const signaturePad = new SignaturePad(canvas);\n\n \/\/ Set today's date as default for dischargeDate\n document.getElementById(\"dischargeDate\").valueAsDate = new Date();\n\n function resizeCanvas() {\n const ratio = Math.max(window.devicePixelRatio || 1, 1);\n canvas.width = canvas.offsetWidth * ratio;\n canvas.height = canvas.offsetHeight * ratio;\n canvas.getContext(\"2d\").scale(ratio, ratio);\n signaturePad.clear(); \/\/ clear after resize\n }\n\n window.addEventListener(\"resize\", resizeCanvas);\n resizeCanvas();\n\n let userIP = \"Fetching...\";\n fetch(\"https:\/\/api.ipify.org?format=json\")\n .then(response => response.json())\n .then(data => { userIP = data.ip; })\n .catch(() => { userIP = \"Unavailable\"; });\n\n document.getElementById(\"clearSignature\").addEventListener(\"click\", () => {\n signaturePad.clear();\n });\n\n document.getElementById(\"submitForm\").addEventListener(\"click\", () => {\n const name = document.getElementById(\"patientName\").value.trim();\n const date = document.getElementById(\"dischargeDate\").value;\n\n if (!name || !date || signaturePad.isEmpty()) {\n alert(\"Veuillez remplir tous les champs et signer avant de soumettre.\");\n return;\n }\n\n const consentCheckbox = document.getElementById(\"consentCheckbox\");\n if (!consentCheckbox.checked) {\n alert(\"Veuillez confirmer que vous avez lu et accept\u00e9 les termes avant de soumettre.\");\n return;\n }\n\n const estDate = new Date().toLocaleString(\"fr-CA\", { timeZone: \"America\/Toronto\" });\n const browserInfo = navigator.userAgent;\n\n const metaDiv = document.getElementById(\"signatureMetadata\");\n metaDiv.innerText = `Sign\u00e9 le ${estDate} (EST)\\nNavigateur : ${browserInfo}\\nIP : ${userIP}`;\n\n const appointmentId = new URLSearchParams(window.location.search).get('appointmentId');\n const signature = signaturePad.toDataURL();\n\n \/\/ Convert canvas to image\n const signatureImg = new Image();\n signatureImg.src = signature;\n signatureImg.style.width = '100%';\n signatureImg.style.maxWidth = '600px';\n\n \/\/ Replace canvas with static image before PDF\n const canvasEl = document.getElementById(\"signature-pad\");\n canvasEl.parentNode.replaceChild(signatureImg, canvasEl);\n\n document.getElementById(\"submitForm\").style.display = \"none\";\n document.getElementById(\"clearSignature\").style.display = \"none\";\n document.getElementById(\"successMessage\").style.display = \"none\";\n document.getElementById(\"errorMessage\").style.display = \"none\";\n\n function generatePdfAndUpload() {\n requestAnimationFrame(() => {\n html2pdf()\n .set({\n html2canvas: {\n scale: 1.5,\n useCORS: true,\n logging: true,\n scrollY: 0\n }\n })\n .from(document.getElementById(\"pdf-wrapper\"))\n .outputPdf('blob')\n .then((pdfBlob) => {\n \/\/ Convert PDF blob to base64 and send to backend as JSON\n const reader = new FileReader();\n reader.onloadend = function () {\n const base64PDF = reader.result.split(',')[1]; \/\/ Remove data:application\/pdf;base64,\n const payload = {\n relatedId: relatedObjectId,\n formType: \"intake\",\n base64PDF,\n fileName: `Intake - ${name}.pdf`\n };\n\n fetch(\"https:\/\/api.summittravelhealthdev.com\/v1\/pdf\/uploadPatientAgreementForm\", {\n method: \"POST\",\n headers: { \"Content-Type\": \"application\/json\" },\n body: JSON.stringify(payload),\n })\n .then(response => {\n if (!response.ok) throw new Error(\"Upload failed\");\n return response.json();\n })\n .then(data => {\n console.log(\"Uploaded to backend:\", data);\n document.getElementById(\"successMessage\").style.display = \"block\";\n \/\/ Save locally after successful upload\n if (typeof saveAs !== \"undefined\") {\n saveAs(pdfBlob, `intake-${name}.pdf`);\n } else {\n const url = URL.createObjectURL(pdfBlob);\n const a = document.createElement(\"a\");\n a.href = url;\n a.download = `intake-${name}.pdf`;\n document.body.appendChild(a);\n a.click();\n document.body.removeChild(a);\n URL.revokeObjectURL(url);\n }\n })\n .catch(err => {\n console.error(err);\n document.getElementById(\"errorMessage\").style.display = \"block\";\n });\n };\n reader.readAsDataURL(pdfBlob);\n });\n });\n }\n\n if (signatureImg.complete) {\n generatePdfAndUpload();\n } else {\n signatureImg.onload = generatePdfAndUpload;\n }\n });\n\/\/ FileSaver.js for saveAs\n<\/script>\n<script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/FileSaver.js\/2.0.5\/FileSaver.min.js\"><\/script>\n\n<\/body>\n<\/html>\n","protected":false},"excerpt":{"rendered":"<p>Formulaire d\u2019admission du patient – Summit Health Formulaire d\u2019admission du patient – Summit Health Nom complet du patient Date Reconnaissances \u00e0 l\u2019admission Je donne par … <a title=\"Formulaire de consentement \u00e0 la prise en charge de la perfusion\" class=\"read-more\" href=\"https:\/\/summithealth.ca\/fr\/formulaire-de-consentement-a-la-prise-en-charge-de-la-perfusion\/\" aria-label=\"En savoir plus sur Formulaire de consentement \u00e0 la prise en charge de la perfusion\">Lire plus<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2080","page","type-page","status-publish"],"yoast_head":"\n<title>Formulaire de consentement \u00e0 la prise en charge de la perfusion - Summit Health<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/summithealth.ca\/fr\/formulaire-de-consentement-a-la-prise-en-charge-de-la-perfusion\/\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Formulaire de consentement \u00e0 la prise en charge de la perfusion - Summit Health\" \/>\n<meta property=\"og:description\" content=\"Formulaire d\u2019admission du patient – Summit Health Formulaire d\u2019admission du patient – Summit Health Nom complet du patient Date Reconnaissances \u00e0 l\u2019admission Je donne par ... 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{"id":2080,"date":"2025-06-26T20:12:47","date_gmt":"2025-06-26T20:12:47","guid":{"rendered":"https:\/\/summithealth.ca\/formulaire-de-consentement-a-la-prise-en-charge-de-la-perfusion\/"},"modified":"2025-08-08T18:43:34","modified_gmt":"2025-08-08T18:43:34","slug":"formulaire-de-consentement-a-la-prise-en-charge-de-la-perfusion","status":"publish","type":"page","link":"https:\/\/summithealth.ca\/fr\/formulaire-de-consentement-a-la-prise-en-charge-de-la-perfusion\/","title":{"rendered":"Formulaire de consentement \u00e0 la prise en charge de la perfusion"},"content":{"rendered":"\n\n\n\n \n Formulaire d\u2019admission du patient – Summit Health<\/title>\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n <link href=\"https:\/\/cdn.jsdelivr.net\/npm\/bootstrap@5.0.1\/dist\/css\/bootstrap.min.css\" rel=\"stylesheet\">\n <script src=\"https:\/\/cdn.jsdelivr.net\/npm\/signature_pad@4.1.5\/dist\/signature_pad.umd.min.js\"><\/script>\n <script src=\"https:\/\/ajax.googleapis.com\/ajax\/libs\/jquery\/3.6.0\/jquery.min.js\"><\/script>\n <script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/html2pdf.js\/0.10.1\/html2pdf.bundle.min.js\"><\/script>\n <style>\n html, body {\n margin: 0;\n padding: 0;\n background: #fff;\n }\n * {\n box-sizing: border-box;\n }\n body {\n padding: 20px;\n font-family: sans-serif;\n font-size: 14px;\n }\n #signature-pad {\n border: 1px solid #ccc;\n width: 100%;\n max-width: 600px;\n height: 200px;\n }\n canvas {\n touch-action: none;\n display: block;\n }\n <\/style>\n<\/head>\n<body>\n\n<div id=\"pdf-wrapper\" style=\"background-color: #fff; color: #000; padding: 20px; margin: 0 auto; max-width: 800px; min-height: 100vh; box-sizing: border-box;\">\n <h2 class=\"mb-4\">Formulaire d\u2019admission du patient – Summit Health<\/h2>\n\n <div class=\"mb-3\">\n <label for=\"patientName\" class=\"form-label\"><strong>Nom complet du patient<\/strong><\/label>\n <input type=\"text\" class=\"form-control\" id=\"patientName\" placeholder=\"Entrez le nom complet\">\n <\/div>\n\n <div class=\"mb-3\">\n <label for=\"dischargeDate\" class=\"form-label\"><strong>Date<\/strong><\/label>\n <input type=\"date\" class=\"form-control\" id=\"dischargeDate\">\n <\/div>\n\n <div id=\"intakeSection\" style=\"display: block;\">\n <p><strong>Reconnaissances \u00e0 l\u2019admission<\/strong><\/p>\n <ul>\n <li>Je donne par la pr\u00e9sente mon consentement \u00e9clair\u00e9 pour recevoir une perfusion intraveineuse chez Summit Health, apr\u00e8s avoir eu l\u2019opportunit\u00e9 de poser des questions concernant la nature, les risques, les b\u00e9n\u00e9fices et les alternatives au traitement propos\u00e9. Je comprends que je peux retirer ce consentement \u00e0 tout moment avant ou pendant la proc\u00e9dure.<\/li>\n <li>Je reconnais et accepte la politique d\u2019annulation de Summit Health, qui stipule que les annulations faites dans les 48 heures pr\u00e9c\u00e9dant l\u2019heure pr\u00e9vue du rendez-vous, ou le fait de ne pas se pr\u00e9senter au rendez-vous, peuvent entra\u00eener des frais non remboursables de 60 $. Je comprends que cette politique vise \u00e0 assurer un acc\u00e8s rapide pour les autres patients.<\/li>\n <li>Si je fournis mon propre m\u00e9dicament pour la perfusion, je d\u00e9clare que le produit a \u00e9t\u00e9 stock\u00e9 et transport\u00e9 conform\u00e9ment aux directives pharmaceutiques, y compris le maintien de la cha\u00eene du froid lorsque requis. J\u2019accepte l\u2019enti\u00e8re responsabilit\u00e9 l\u00e9gale de l\u2019int\u00e9grit\u00e9 du m\u00e9dicament et d\u00e9gage Summit Health de toute responsabilit\u00e9 li\u00e9e \u00e0 une mauvaise manipulation ou aux effets ind\u00e9sirables caus\u00e9s par l\u2019\u00e9tat du produit.<\/li>\n <li>Si je re\u00e7ois de la Benadryl (diphenhydramine) ou tout autre m\u00e9dicament s\u00e9datif dans le cadre de mon traitement, je reconnais avoir \u00e9t\u00e9 inform\u00e9 de ne pas conduire, manipuler des machines lourdes ou effectuer toute activit\u00e9 n\u00e9cessitant une vigilance mentale pendant au moins 8 heures apr\u00e8s l\u2019administration. J\u2019accepte toute responsabilit\u00e9 l\u00e9gale pour les cons\u00e9quences de la non-observation de ce conseil.<\/li>\n <\/ul>\n <\/div>\n\n <div id=\"dischargeSection\" style=\"display: none;\">\n <p><strong>Reconnaissance de sortie<\/strong><\/p>\n <ul>\n <li>Je reconnais avoir choisi de quitter la clinique avant la fin de la p\u00e9riode de surveillance post-perfusion recommand\u00e9e de 60 minutes. Je comprends les risques potentiels associ\u00e9s et d\u00e9gage Summit Health de toute responsabilit\u00e9 en cas de r\u00e9action ou complication retard\u00e9e apr\u00e8s mon d\u00e9part.<\/li>\n <\/ul>\n <\/div>\n\n <div class=\"form-check mb-3\">\n <input class=\"form-check-input\" type=\"checkbox\" value=\"\" id=\"consentCheckbox\">\n <label class=\"form-check-label\" for=\"consentCheckbox\">\n Je confirme avoir lu et compris les informations ci-dessus et j\u2019accepte les termes et conditions.\n <\/label>\n <\/div>\n\n <div class=\"mb-3\">\n <label class=\"form-label\"><strong>Signature<\/strong><\/label><br>\n <canvas id=\"signature-pad\"><\/canvas><br>\n <button class=\"btn btn-secondary mt-2\" id=\"clearSignature\">Effacer la signature<\/button>\n <\/div>\n\n <div id=\"signatureMetadata\" class=\"mb-3\" style=\"font-size: 12px; color: #555;\"><\/div>\n\n <button class=\"btn btn-primary\" id=\"submitForm\">Soumettre le formulaire<\/button>\n\n <div class=\"alert alert-success mt-3\" style=\"display: none;\" id=\"successMessage\">\n Le formulaire de consentement a \u00e9t\u00e9 soumis avec succ\u00e8s.\n <\/div>\n <div class=\"alert alert-danger mt-3\" style=\"display: none;\" id=\"errorMessage\">\n Une erreur s’est produite lors de la soumission du formulaire. Veuillez en informer votre infirmier(\u00e8re).\n <\/div>\n<\/div>\n\n<script>\n const urlParams = new URLSearchParams(window.location.search);\n const relatedObjectId = urlParams.get(\"relatedObjectId\");\n\n if (!relatedObjectId) {\n document.getElementById(\"pdf-wrapper\").innerHTML = '<div class=\"alert alert-danger\">Ce formulaire contient une erreur technique. 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