{"id":5670,"date":"2024-09-11T11:56:17","date_gmt":"2024-09-11T15:56:17","guid":{"rendered":"https:\/\/atelierprostho.com\/refer\/"},"modified":"2025-09-30T18:38:54","modified_gmt":"2025-09-30T22:38:54","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/atelierprostho.com\/en\/refer-a-patient\/","title":{"rendered":"Refer a patient"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5670\" class=\"elementor elementor-5670 elementor-5171\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-614c8a0 e-con-full e-flex e-con e-parent\" data-id=\"614c8a0\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-a4a2b13 e-con-full e-flex e-con e-child\" data-id=\"a4a2b13\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-1c06c1b e-con-full e-flex e-con e-child\" data-id=\"1c06c1b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c773d6f animated-slow elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"c773d6f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;,&quot;_animation_mobile&quot;:&quot;fadeInDown&quot;,&quot;_animation_mobile_extra&quot;:&quot;fadeInDown&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Refer a patient<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b4ebc1b e-con-full animated-slow e-flex elementor-invisible e-con e-parent\" data-id=\"b4ebc1b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;fadeIn&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-3ef44ba e-con-full e-flex e-con e-child\" data-id=\"3ef44ba\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c71c21d custom-form-link elementor-widget elementor-widget-wpforms\" data-id=\"c71c21d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-elementor-widget-c71c21d\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-c71c21d {\n\t\t\t\t--wpforms-field-text-color: #393939;\n--wpforms-label-color: #393939;\n--wpforms-label-sublabel-color: #393939;\n--wpforms-button-background-color: #B76F3F;\n--wpforms-field-size-input-height: 50px;\n--wpforms-field-size-input-spacing: 20px;\n--wpforms-field-size-font-size: 18px;\n--wpforms-field-size-line-height: 21px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 18px;\n--wpforms-field-size-sublabel-spacing: 10px;\n--wpforms-field-size-icon-size: 1.25;\n--wpforms-label-size-font-size: 18px;\n--wpforms-label-size-line-height: 21px;\n--wpforms-label-size-sublabel-font-size: 16px;\n--wpforms-label-size-sublabel-line-height: 19px;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-6293\"><form id=\"wpforms-form-6293\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"6293\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/5670?wpforms_form_id=6293\" data-token=\"70e264d5f55e568a2d670f274c3f80d4\" data-token-time=\"1777506156\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-6293-field_2-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"2\"><fieldset><legend class=\"wpforms-field-label\">Specialist: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-6293-field_2\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_2_1\" name=\"wpforms[fields][2]\" value=\"Dr. Olivier C\u00f4t\u00e9 - Periodontist\" aria-errormessage=\"wpforms-6293-field_2_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_2_1\">Dr. Olivier C\u00f4t\u00e9 - Periodontist<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_2_7\" name=\"wpforms[fields][2]\" value=\"Dr. Pierre-Olivier Miron - Endodontist\" aria-errormessage=\"wpforms-6293-field_2_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_2_7\">Dr. Pierre-Olivier Miron - Endodontist<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_2_2\" name=\"wpforms[fields][2]\" value=\"Dr. M\u00e9lissa Lam - Prosthodontist\" aria-errormessage=\"wpforms-6293-field_2_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_2_2\">Dr. M\u00e9lissa Lam - Prosthodontist<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_2_3\" name=\"wpforms[fields][2]\" value=\"Dr. Eric Dufresne - Prosthodontist\" aria-errormessage=\"wpforms-6293-field_2_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_2_3\">Dr. Eric Dufresne - Prosthodontist<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_2_4\" name=\"wpforms[fields][2]\" value=\"Dr. Yannie Chea - Prosthodontist\" aria-errormessage=\"wpforms-6293-field_2_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_2_4\">Dr. Yannie Chea - Prosthodontist<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_2_5\" name=\"wpforms[fields][2]\" value=\"Dr. Anne Beaudin - Prosthodontist\" aria-errormessage=\"wpforms-6293-field_2_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_2_5\">Dr. Anne Beaudin - Prosthodontist<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_2_6\" name=\"wpforms[fields][2]\" value=\"First availability\" aria-errormessage=\"wpforms-6293-field_2_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_2_6\">First availability<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_5-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Referred:<\/legend><ul id=\"wpforms-6293-field_5\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_5_1\" name=\"wpforms[fields][5][]\" value=\"Removable partial prosthesis\" aria-errormessage=\"wpforms-6293-field_5_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_5_1\">Removable partial prosthesis<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_5_2\" name=\"wpforms[fields][5][]\" value=\"Complete removable prosthesis\" aria-errormessage=\"wpforms-6293-field_5_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_5_2\">Complete removable prosthesis<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_5_3\" name=\"wpforms[fields][5][]\" value=\"Fixed on natural teeth\" aria-errormessage=\"wpforms-6293-field_5_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_5_3\">Fixed on natural teeth<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_5_4\" name=\"wpforms[fields][5][]\" value=\"Implant\" aria-errormessage=\"wpforms-6293-field_5_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_5_4\">Implant<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_5_5\" name=\"wpforms[fields][5][]\" value=\"Aesthetic\" aria-errormessage=\"wpforms-6293-field_5_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_5_5\">Aesthetic<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_5_6\" name=\"wpforms[fields][5][]\" value=\"ATM disorder and occlusion\" aria-errormessage=\"wpforms-6293-field_5_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_5_6\">ATM disorder and occlusion<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_5_7\" name=\"wpforms[fields][5][]\" value=\"Other(s):\" aria-errormessage=\"wpforms-6293-field_5_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_5_7\">Other(s):<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_6-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-hide\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_6\">Details on the consultation.<\/label><textarea id=\"wpforms-6293-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-6293-field_6-error\" ><\/textarea><\/div><div id=\"wpforms-6293-field_8-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"8\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Referred:<\/legend><ul id=\"wpforms-6293-field_8\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_8_1\" name=\"wpforms[fields][8][]\" value=\"Periodontal disease\" aria-errormessage=\"wpforms-6293-field_8_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_8_1\">Periodontal disease<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_8_2\" name=\"wpforms[fields][8][]\" value=\"Mucogingival surgery\" aria-errormessage=\"wpforms-6293-field_8_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_8_2\">Mucogingival surgery<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_8_3\" name=\"wpforms[fields][8][]\" value=\"Implantology\" aria-errormessage=\"wpforms-6293-field_8_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_8_3\">Implantology<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_8_4\" name=\"wpforms[fields][8][]\" value=\"Peri-implant disease\" aria-errormessage=\"wpforms-6293-field_8_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_8_4\">Peri-implant disease<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_8_5\" name=\"wpforms[fields][8][]\" value=\"Gingival pathology\" aria-errormessage=\"wpforms-6293-field_8_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_8_5\">Gingival pathology<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_8_7\" name=\"wpforms[fields][8][]\" value=\"Other(s):\" aria-errormessage=\"wpforms-6293-field_8_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_8_7\">Other(s):<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_9-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"9\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_9\">Notes for the periodontist.<\/label><textarea id=\"wpforms-6293-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-6293-field_9-error\" ><\/textarea><\/div><div id=\"wpforms-6293-field_30-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><div class=\"wpforms-field-layout-columns wpforms-field-layout-preset-50-50\"><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-6293-field_45-container\" class=\"wpforms-field wpforms-field-checkbox right-top wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Top-Right<\/legend><ul id=\"wpforms-6293-field_45\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_1\" name=\"wpforms[fields][45][]\" value=\"18\" aria-errormessage=\"wpforms-6293-field_45_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_1\">18<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_2\" name=\"wpforms[fields][45][]\" value=\"17\" aria-errormessage=\"wpforms-6293-field_45_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_2\">17<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_3\" name=\"wpforms[fields][45][]\" value=\"16\" aria-errormessage=\"wpforms-6293-field_45_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_3\">16<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_4\" name=\"wpforms[fields][45][]\" value=\"15\" aria-errormessage=\"wpforms-6293-field_45_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_4\">15<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_5\" name=\"wpforms[fields][45][]\" value=\"14\" aria-errormessage=\"wpforms-6293-field_45_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_5\">14<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_6\" name=\"wpforms[fields][45][]\" value=\"13\" aria-errormessage=\"wpforms-6293-field_45_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_6\">13<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_7\" name=\"wpforms[fields][45][]\" value=\"12\" aria-errormessage=\"wpforms-6293-field_45_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_7\">12<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_45_8\" name=\"wpforms[fields][45][]\" value=\"11\" aria-errormessage=\"wpforms-6293-field_45_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_45_8\">11<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_46-container\" class=\"wpforms-field wpforms-field-checkbox right-bottom wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Bottom-Right<\/legend><ul id=\"wpforms-6293-field_46\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_1\" name=\"wpforms[fields][46][]\" value=\"48\" aria-errormessage=\"wpforms-6293-field_46_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_1\">48<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_2\" name=\"wpforms[fields][46][]\" value=\"47\" aria-errormessage=\"wpforms-6293-field_46_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_2\">47<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_3\" name=\"wpforms[fields][46][]\" value=\"46\" aria-errormessage=\"wpforms-6293-field_46_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_3\">46<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_4\" name=\"wpforms[fields][46][]\" value=\"45\" aria-errormessage=\"wpforms-6293-field_46_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_4\">45<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_5\" name=\"wpforms[fields][46][]\" value=\"44\" aria-errormessage=\"wpforms-6293-field_46_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_5\">44<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_6\" name=\"wpforms[fields][46][]\" value=\"43\" aria-errormessage=\"wpforms-6293-field_46_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_6\">43<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_7\" name=\"wpforms[fields][46][]\" value=\"42\" aria-errormessage=\"wpforms-6293-field_46_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_7\">42<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_46_8\" name=\"wpforms[fields][46][]\" value=\"41\" aria-errormessage=\"wpforms-6293-field_46_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_46_8\">41<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\" ><div id=\"wpforms-6293-field_47-container\" class=\"wpforms-field wpforms-field-checkbox left-top wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Top-Left<\/legend><ul id=\"wpforms-6293-field_47\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_1\" name=\"wpforms[fields][47][]\" value=\"21\" aria-errormessage=\"wpforms-6293-field_47_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_1\">21<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_2\" name=\"wpforms[fields][47][]\" value=\"22\" aria-errormessage=\"wpforms-6293-field_47_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_2\">22<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_3\" name=\"wpforms[fields][47][]\" value=\"23\" aria-errormessage=\"wpforms-6293-field_47_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_3\">23<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_4\" name=\"wpforms[fields][47][]\" value=\"24\" aria-errormessage=\"wpforms-6293-field_47_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_4\">24<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_5\" name=\"wpforms[fields][47][]\" value=\"25\" aria-errormessage=\"wpforms-6293-field_47_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_5\">25<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_6\" name=\"wpforms[fields][47][]\" value=\"26\" aria-errormessage=\"wpforms-6293-field_47_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_6\">26<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_7\" name=\"wpforms[fields][47][]\" value=\"27\" aria-errormessage=\"wpforms-6293-field_47_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_7\">27<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_47_8\" name=\"wpforms[fields][47][]\" value=\"28\" aria-errormessage=\"wpforms-6293-field_47_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_47_8\">28<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_48-container\" class=\"wpforms-field wpforms-field-checkbox left-bottom wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Bottom-Left<\/legend><ul id=\"wpforms-6293-field_48\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_1\" name=\"wpforms[fields][48][]\" value=\"31\" aria-errormessage=\"wpforms-6293-field_48_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_1\">31<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_2\" name=\"wpforms[fields][48][]\" value=\"32\" aria-errormessage=\"wpforms-6293-field_48_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_2\">32<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_3\" name=\"wpforms[fields][48][]\" value=\"33\" aria-errormessage=\"wpforms-6293-field_48_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_3\">33<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_4\" name=\"wpforms[fields][48][]\" value=\"34\" aria-errormessage=\"wpforms-6293-field_48_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_4\">34<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_5\" name=\"wpforms[fields][48][]\" value=\"35\" aria-errormessage=\"wpforms-6293-field_48_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_5\">35<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_6\" name=\"wpforms[fields][48][]\" value=\"36\" aria-errormessage=\"wpforms-6293-field_48_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_6\">36<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_7\" name=\"wpforms[fields][48][]\" value=\"37\" aria-errormessage=\"wpforms-6293-field_48_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_7\">37<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_48_8\" name=\"wpforms[fields][48][]\" value=\"38\" aria-errormessage=\"wpforms-6293-field_48_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_48_8\">38<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div>\t\t<div id=\"wpforms-6293-field_1-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"1\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-6293-field_1\" >We the Bottom-Left<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-6293-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-6293-field_49-container\" class=\"wpforms-field wpforms-field-layout wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"49\" style=\"display:none;\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_50-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"50\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Requested Treatment(s):<\/legend><ul id=\"wpforms-6293-field_50\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_50_1\" name=\"wpforms[fields][50][]\" value=\"Consultation only\" aria-errormessage=\"wpforms-6293-field_50_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_50_1\">Consultation only<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_50_2\" name=\"wpforms[fields][50][]\" value=\"Root canal treatment\" aria-errormessage=\"wpforms-6293-field_50_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_50_2\">Root canal treatment<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_50_3\" name=\"wpforms[fields][50][]\" value=\"Retreatment\" aria-errormessage=\"wpforms-6293-field_50_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_50_3\">Retreatment<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_50_4\" name=\"wpforms[fields][50][]\" value=\"Apical Surgery\" aria-errormessage=\"wpforms-6293-field_50_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_50_4\">Apical Surgery<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_50_5\" name=\"wpforms[fields][50][]\" value=\"Other(s):\" aria-errormessage=\"wpforms-6293-field_50_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_50_5\">Other(s):<\/label><\/li><\/ul><\/fieldset><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_52-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"52\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Reason(s):<\/legend><ul id=\"wpforms-6293-field_52\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_52_1\" name=\"wpforms[fields][52][]\" value=\"Symptoms \/ Trauma\" aria-errormessage=\"wpforms-6293-field_52_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_52_1\">Symptoms \/ Trauma<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_52_2\" name=\"wpforms[fields][52][]\" value=\"Lesion \/ Fistula\" aria-errormessage=\"wpforms-6293-field_52_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_52_2\">Lesion \/ Fistula<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_52_3\" name=\"wpforms[fields][52][]\" value=\"Pre-prosthetic\" aria-errormessage=\"wpforms-6293-field_52_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_52_3\">Pre-prosthetic<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_52_4\" name=\"wpforms[fields][52][]\" value=\"Prior treatment to be evaluated\" aria-errormessage=\"wpforms-6293-field_52_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_52_4\">Prior treatment to be evaluated<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_52_5\" name=\"wpforms[fields][52][]\" value=\"Cannot complete (Notes Please)\" aria-errormessage=\"wpforms-6293-field_52_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_52_5\">Cannot complete (Notes Please)<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-6293-field_43-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">What restoration do you desire from the endodontist?<\/legend><ul id=\"wpforms-6293-field_43\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_43_1\" name=\"wpforms[fields][43][]\" value=\"Temporary\" aria-errormessage=\"wpforms-6293-field_43_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_43_1\">Temporary<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_43_2\" name=\"wpforms[fields][43][]\" value=\"Composite\" aria-errormessage=\"wpforms-6293-field_43_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_43_2\">Composite<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_43_3\" name=\"wpforms[fields][43][]\" value=\"Amalgam\" aria-errormessage=\"wpforms-6293-field_43_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_43_3\">Amalgam<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_43_4\" name=\"wpforms[fields][43][]\" value=\"+ Prefabricated pivot\" aria-errormessage=\"wpforms-6293-field_43_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_43_4\">+ Prefabricated pivot<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_44-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">What restoration are you planning?<\/legend><ul id=\"wpforms-6293-field_44\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_44_1\" name=\"wpforms[fields][44][]\" value=\"Composite\" aria-errormessage=\"wpforms-6293-field_44_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_44_1\">Composite<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_44_2\" name=\"wpforms[fields][44][]\" value=\"Amalgam\" aria-errormessage=\"wpforms-6293-field_44_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_44_2\">Amalgam<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_44_3\" name=\"wpforms[fields][44][]\" value=\"Crown\" aria-errormessage=\"wpforms-6293-field_44_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_44_3\">Crown<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_44_4\" name=\"wpforms[fields][44][]\" value=\"Inlay \/ CEREC\" aria-errormessage=\"wpforms-6293-field_44_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_44_4\">Inlay \/ CEREC<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_41-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Do you want a Pivot Space?<\/legend><ul id=\"wpforms-6293-field_41\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_41_1\" name=\"wpforms[fields][41]\" value=\"Yes\" aria-errormessage=\"wpforms-6293-field_41_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_41_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_41_2\" name=\"wpforms[fields][41]\" value=\"No\" aria-errormessage=\"wpforms-6293-field_41_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_41_2\">No<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_41_3\" name=\"wpforms[fields][41]\" value=\"According to your opinion\" aria-errormessage=\"wpforms-6293-field_41_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_41_3\">According to your opinion<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_29-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_29\">Notes for the endodontist.<\/label><textarea id=\"wpforms-6293-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" aria-errormessage=\"wpforms-6293-field_29-error\" ><\/textarea><\/div><div id=\"wpforms-6293-field_16-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"16\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tPatient&#039;s Information\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_17-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_17\">Patient&#039;s Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6293-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" aria-errormessage=\"wpforms-6293-field_17-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_19-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Date of birth: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-medium\"><select name=\"wpforms[fields][19][date][d]\" id=\"wpforms-6293-field_19-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][19][date][m]\" id=\"wpforms-6293-field_19-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][19][date][y]\" id=\"wpforms-6293-field_19-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_18-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_18\">Telephone: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-6293-field_18\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][18]\" aria-label=\"Telephone:\" aria-errormessage=\"wpforms-6293-field_18-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_20-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_20\">Email address of referred patient: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-6293-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" spellcheck=\"false\" aria-errormessage=\"wpforms-6293-field_20-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-6293-field_10-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"10\"><h3 class=\"wpforms-field-label\">\n\t\t\t\tInformation of the referring dentist\n\t\t\t<\/h3><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_11-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_11\">Name of referring dentist: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6293-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-6293-field_11-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_12-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_12\">Today&#039;s date: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-6293-field_12\" 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][12][date]\" aria-errormessage=\"wpforms-6293-field_12-error\" 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><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_13-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_13\">Telephone: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-6293-field_13\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][13]\" aria-label=\"Telephone:\" aria-errormessage=\"wpforms-6293-field_13-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-6293-field_14-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_14\">Email address of referring dentist: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-6293-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" spellcheck=\"false\" aria-errormessage=\"wpforms-6293-field_14-error\" required><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-6293-field_15-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"15\"><fieldset><legend class=\"wpforms-field-label\">We will send you a written report by email. Would you like to receive a printed version of this consultation report instead? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-6293-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_15_1\" name=\"wpforms[fields][15]\" value=\"Yes\" aria-errormessage=\"wpforms-6293-field_15_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_15_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_15_2\" name=\"wpforms[fields][15]\" value=\"No\" aria-errormessage=\"wpforms-6293-field_15_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_15_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_22-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">X-ray included:<\/legend><ul id=\"wpforms-6293-field_22\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_22_1\" name=\"wpforms[fields][22]\" value=\"Panorex\" aria-errormessage=\"wpforms-6293-field_22_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_22_1\">Panorex<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_22_2\" name=\"wpforms[fields][22]\" value=\"BW\" aria-errormessage=\"wpforms-6293-field_22_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_22_2\">BW<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_22_3\" name=\"wpforms[fields][22]\" value=\"PA\" aria-errormessage=\"wpforms-6293-field_22_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_22_3\">PA<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-6293-field_22_4\" name=\"wpforms[fields][22]\" value=\"Other(s):\" aria-errormessage=\"wpforms-6293-field_22_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_22_4\">Other(s):<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6293-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_23\">Comments<\/label><textarea id=\"wpforms-6293-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" aria-errormessage=\"wpforms-6293-field_23-error\" ><\/textarea><\/div><div id=\"wpforms-6293-field_25-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_25\">X-rays:<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"25\"\n\t\tdata-form-id=\"6293\"\n\t\tdata-input-name=\"wpforms_6293_25\"\n\t\tdata-extensions=\"png,jpg,jpeg,pdf\"\n\t\tdata-max-size=\"10485760\"\n\t\tdata-max-file-number=\"5\"\n\t\tdata-post-max-size=\"2147483648\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 5 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-6293-field_25\"\n\t\tname=\"wpforms_6293_25\" \t\tvalue=\"\">\n<div id=\"wpforms-6293-field_25-description\" class=\"wpforms-field-description\">Maximum size of each file: 10 MB. File types: .png, .jpg, .jpeg, .pdf<\/div><\/div><div id=\"wpforms-6293-field_28-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-6293-field_28\">Upload the medical questionnaire if it is less than twelve months old:<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"28\"\n\t\tdata-form-id=\"6293\"\n\t\tdata-input-name=\"wpforms_6293_28\"\n\t\tdata-extensions=\"pdf\"\n\t\tdata-max-size=\"10485760\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"2147483648\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-6293-field_28\"\n\t\tname=\"wpforms_6293_28\" \t\tvalue=\"\">\n<div id=\"wpforms-6293-field_28-description\" class=\"wpforms-field-description\">Maximum file size: 10 MB. File type: .pdf<\/div><\/div><div id=\"wpforms-6293-field_26-container\" class=\"wpforms-field wpforms-field-gdpr-checkbox\" data-field-id=\"26\"><label class=\"wpforms-field-label\">Cookies and Privacy Policy: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><ul id=\"wpforms-6293-field_26\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-6293-field_26_1\" name=\"wpforms[fields][26][]\" value=\"I agree that Atelier Prostho manages the personal information provided in this form in accordance with the cookie policy and privacy statement that I have read and understood.\" aria-errormessage=\"wpforms-6293-field_26_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6293-field_26_1\">I agree that Atelier Prostho manages the personal information provided in this form in accordance with the cookie policy and privacy statement that I have read and understood.<\/label><\/li><\/ul><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-6293-field_1-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-6293-field_1-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-6293-field_1-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"6293\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/pages\/5670\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-6293\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/atelierprostho.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-426f6be e-con-full e-flex e-con e-parent\" data-id=\"426f6be\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3705 elementor-button-info elementor-align-right elementor-fixed elementor-widget elementor-widget-global elementor-global-3705 elementor-widget-button\" data-id=\"3705\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_position&quot;:&quot;fixed&quot;,&quot;motion_fx_motion_fx_scrolling&quot;:&quot;yes&quot;,&quot;motion_fx_opacity_effect&quot;:&quot;yes&quot;,&quot;motion_fx_opacity_direction&quot;:&quot;out-in&quot;,&quot;motion_fx_opacity_level&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:10,&quot;sizes&quot;:[]},&quot;motion_fx_opacity_range&quot;:{&quot;unit&quot;:&quot;%&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:{&quot;start&quot;:20,&quot;end&quot;:80}},&quot;motion_fx_devices&quot;:[&quot;widescreen&quot;,&quot;desktop&quot;,&quot;laptop&quot;,&quot;tablet_extra&quot;,&quot;tablet&quot;,&quot;mobile_extra&quot;,&quot;mobile&quot;]}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm elementor-animation-bob\" href=\"#top\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-arrow-up\" viewBox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M34.9 289.5l-22.2-22.2c-9.4-9.4-9.4-24.6 0-33.9L207 39c9.4-9.4 24.6-9.4 33.9 0l194.3 194.3c9.4 9.4 9.4 24.6 0 33.9L413 289.4c-9.5 9.5-25 9.3-34.3-.4L264 168.6V456c0 13.3-10.7 24-24 24h-32c-13.3 0-24-10.7-24-24V168.6L69.2 289.1c-9.3 9.8-24.8 10-34.3.4z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Does your patient require specialized care?<br \/>\nRefer them to our clinic!<\/p>\n","protected":false},"author":1,"featured_media":3839,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-5670","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/pages\/5670","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/comments?post=5670"}],"version-history":[{"count":2,"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/pages\/5670\/revisions"}],"predecessor-version":[{"id":7326,"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/pages\/5670\/revisions\/7326"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/media\/3839"}],"wp:attachment":[{"href":"https:\/\/atelierprostho.com\/en\/wp-json\/wp\/v2\/media?parent=5670"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}