{"id":1526,"date":"2022-12-14T15:20:34","date_gmt":"2022-12-14T15:20:34","guid":{"rendered":"https:\/\/www.dentistsouthealing.com\/?page_id=1526"},"modified":"2023-09-11T11:46:39","modified_gmt":"2023-09-11T11:46:39","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/www.dentistsouthealing.com\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1526\" class=\"elementor elementor-1526\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-5cdcf478 elementor-section-full_width elementor-section-stretched elementor-section-height-default elementor-section-height-default\" data-id=\"5cdcf478\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div 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.elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Patient Referral Form<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-3afdb696\" data-id=\"3afdb696\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-25cde04b elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"25cde04b\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-22e1a164\" data-id=\"22e1a164\" 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.e-font-icon-svg{height:1em}.elementor-select-wrapper .select-caret-down-wrapper{position:absolute;top:50%;transform:translateY(-50%);inset-inline-end:10px;pointer-events:none;font-size:11px}.elementor-select-wrapper .select-caret-down-wrapper svg{display:unset;width:1em;aspect-ratio:unset;fill:currentColor}.elementor-select-wrapper .select-caret-down-wrapper i{font-size:19px;line-height:2}.elementor-select-wrapper.remove-before:before{content:\"\"!important}<\/style>\t\t<form class=\"elementor-form\" method=\"post\" name=\"Referral Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"1526\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"38e060d5\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-referralFor elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-referralFor\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReferral For:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"CBCT\" id=\"form-field-referralFor-0\" name=\"form_fields[referralFor][]\"> <label for=\"form-field-referralFor-0\">CBCT<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Dental Implants\" id=\"form-field-referralFor-1\" name=\"form_fields[referralFor][]\"> <label for=\"form-field-referralFor-1\">Dental Implants<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Periodontics \" id=\"form-field-referralFor-2\" name=\"form_fields[referralFor][]\"> <label for=\"form-field-referralFor-2\">Periodontics <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Orthodontics \" id=\"form-field-referralFor-3\" name=\"form_fields[referralFor][]\"> <label for=\"form-field-referralFor-3\">Orthodontics <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Endodontics\" id=\"form-field-referralFor-4\" name=\"form_fields[referralFor][]\"> <label for=\"form-field-referralFor-4\">Endodontics<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anti wrinkle treatment \" id=\"form-field-referralFor-5\" name=\"form_fields[referralFor][]\"> <label for=\"form-field-referralFor-5\">Anti wrinkle treatment <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patientTitle elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientTitle\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Title\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patientTitle]\" id=\"form-field-patientTitle\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patientName elementor-col-70 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientName\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient First & Last Name:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patientName]\" id=\"form-field-patientName\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patientDOB elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientDOB\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Date of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patientDOB]\" id=\"form-field-patientDOB\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\" dd\/mm\/yyyy\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-patientNumber elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientNumber\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[patientNumber]\" id=\"form-field-patientNumber\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patientAddress elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientAddress\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patientAddress]\" id=\"form-field-patientAddress\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patientPostCode elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientPostCode\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPostal Code\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patientPostCode]\" id=\"form-field-patientPostCode\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-patientMedicalHistory elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientMedicalHistory\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient Medical History\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[patientMedicalHistory]\" id=\"form-field-patientMedicalHistory\" rows=\"4\" required=\"required\" aria-required=\"true\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-patientOralClinicalObservation elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientOralClinicalObservation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPatient's Oral & Clinical Observations\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[patientOralClinicalObservation]\" id=\"form-field-patientOralClinicalObservation\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-patientAttachments elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientAttachments\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAttachments\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[patientAttachments]\" id=\"form-field-patientAttachments\" class=\"elementor-field elementor-size-sm  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2158075 elementor-col-100\">\n\t\t\t\t\t<span id=\"ecd\">Dentist Details<\/span>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dentistName elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentistName\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDentist's Full Name:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[dentistName]\" id=\"form-field-dentistName\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-referreingDentist elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-referreingDentist\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReferring Dentist's Dental Practice Details\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[referreingDentist]\" id=\"form-field-referreingDentist\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-dentistPhoneNumber elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentistPhoneNumber\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDentist's Phone Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[dentistPhoneNumber]\" id=\"form-field-dentistPhoneNumber\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-dentistEmail elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentistEmail\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDentist's Email\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[dentistEmail]\" id=\"form-field-dentistEmail\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" aria-required=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-acceptance elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-acceptance\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tConsent\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[acceptance]\" id=\"form-field-acceptance\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\">\n\t\t\t\t<label for=\"form-field-acceptance\">I\u2019d like to be informed of exclusive offers and other practice information.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-reCaptchaV3 elementor-col-100 recaptcha_v3-bottomright\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-reCaptchaV3\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LdczsMbAAAAAOUlDiw4Qz8IkbB6neYB0UPyWdnK\" data-type=\"v3\" data-action=\"Form\" data-badge=\"bottomright\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button type=\"submit\" class=\"elementor-button elementor-size-md\">\n\t\t\t\t\t\t<span >\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\" elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send Referral<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-inner-column elementor-element elementor-element-725e76f1\" data-id=\"725e76f1\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Referral Form<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"","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":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","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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