{"id":354,"date":"2023-03-19T13:17:00","date_gmt":"2023-03-19T03:17:00","guid":{"rendered":"https:\/\/dentalsedation.website\/?page_id=354"},"modified":"2023-11-11T11:21:12","modified_gmt":"2023-11-11T01:21:12","slug":"patient-referral","status":"publish","type":"page","link":"https:\/\/dentalsedation.website\/index.php\/patient-referral\/","title":{"rendered":"Patient Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"354\" class=\"elementor elementor-354\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-aff3549 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"aff3549\" 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-100 elementor-top-column elementor-element elementor-element-764092e\" data-id=\"764092e\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-615a478 elementor-widget elementor-widget-wpforms\" data-id=\"615a478\" data-element_type=\"widget\" data-widget_type=\"wpforms.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\r\n<style type=\"text\/css\">\r\n\r\n\r\n\r\nbody #wpforms-323 {\r\n\t\t\r\n\t\t\t}\r\n\r\n\t\r\n\r\n\tbody #wpforms-323 .wpforms-head-container {\r\n\t\tborder-width: 0px;}\r\n\r\n\tbody #wpforms-323 .wpforms-head-container .wpforms-title {\r\n\t\t}\r\n\r\n\tbody #wpforms-323 .wpforms-head-container .wpforms-description {\r\n\t\t\t\tdisplay:block;\r\n\t}\r\n\r\n\r\n\tbody #wpforms-323 .wpforms-submit-container .wpforms-submit, body #wpforms-323 .wpforms-field-pagebreak button.wpforms-page-button {\r\n\t\tcolor:#ffffff ;background-color:#518db0 ;\t\tborder-width: 0px;\t}\r\n\r\n\tbody #wpforms-323 .wpforms-submit-container .wpforms-submit:hover, body #wpforms-323 .wpforms-field-pagebreak button.wpforms-page-button:hover {\r\n\t\t\t}\r\n\r\n\tbody #wpforms-323 .wpforms-submit-container,\r\n\tbody #wpforms-323 .wpforms-field-pagebreak .wpforms-pagebreak-left{\r\n\t\t}\r\n\r\n\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field input[type=text],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field input[type=email],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field input[type=tel],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field input[type=url],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field input[type=password],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field input[type=number]\r\n\t{\r\n\t\t\t\tborder-width: 1px;\t}\r\n\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field .wpforms-field-row\r\n\t{\r\n\t\t\t}\r\n\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field-layout.wpforms-field input[type=text],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field-layout.wpforms-field input[type=email],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field-layout.wpforms-field input[type=tel],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field-layout.wpforms-field input[type=url],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field-layout.wpforms-field input[type=password],\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field-layout.wpforms-field input[type=number]{\r\n\t\twidth: 100%;\r\n\t}\r\n\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field .wpforms-field-row input[type=text]{\r\n\t\twidth: 100%;\r\n\t}\r\n\r\n\r\n\r\n\r\n\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field textarea {\r\n\t\t\t\t\tborder-width: 1px;\t}\r\n\r\n\r\n \r\n\tbody #wpforms-323 .wpforms-form .wpforms-field-checkbox li label {\r\n\t\tcolor:#518db0 ;\t}\r\n \r\n\tbody #wpforms-323 .wpforms-form .wpforms-field .wpforms-field-description {\r\n\r\n\t\t\t}\r\n\r\n \r\n\tbody #wpforms-323 .wpforms-form .wpforms-field label.wpforms-field-label,\r\n\tbody #wpforms-323 .wpforms-form .wpforms-field .wpforms-field-label {\r\n\t\tcolor:#f39407 ;\t}\r\n\r\n\r\n\/* Styling for Tablets *\/\r\n@media only screen and (max-width: 800px) and (min-width:481px) {\r\n\t\r\n\r\n\r\n\r\n}\r\n\r\n@media only screen and (max-width: 480px){\r\n\t\r\n\r\n\r\n\r\n}\r\n\/*Option to add custom CSS *\/\r\n\r\n\r\n\r\n\t\t<\/style>\r\n\t\t<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-323\"><form id=\"wpforms-form-323\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"323\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/354\" data-token=\"bf0ce92c2c701b5e920ca0cb7fe9b68f\" data-token-time=\"1777723726\"><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-323-field_13-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"13\"><h3 id=\"wpforms-323-field_13\" aria-errormessage=\"wpforms-323-field_13-error\">PATIENT&#039;S DETAILS<\/h3><\/div><div id=\"wpforms-323-field_7-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"7\"><fieldset><legend class=\"wpforms-field-label\">Patient&#039;s Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-323-field_7\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][7][first]\" aria-errormessage=\"wpforms-323-field_7-error\" required><label for=\"wpforms-323-field_7\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-323-field_7-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][7][last]\" aria-errormessage=\"wpforms-323-field_7-last-error\" required><label for=\"wpforms-323-field_7-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-323-field_8-container\" class=\"wpforms-field wpforms-field-address\" data-field-type=\"address\" data-field-id=\"8\"><fieldset><legend class=\"wpforms-field-label\">Patient&#039;s Address <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-323-field_8\" class=\"wpforms-field-address-address1 wpforms-field-required\" name=\"wpforms[fields][8][address1]\" aria-errormessage=\"wpforms-323-field_8-error\" required><label for=\"wpforms-323-field_8\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-323-field_8-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][8][address2]\" aria-errormessage=\"wpforms-323-field_8-address2-error\" ><label for=\"wpforms-323-field_8-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-323-field_8-city\" class=\"wpforms-field-address-city wpforms-field-required\" name=\"wpforms[fields][8][city]\" aria-errormessage=\"wpforms-323-field_8-city-error\" required><label for=\"wpforms-323-field_8-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-323-field_8-state\" class=\"wpforms-field-address-state wpforms-field-required\" name=\"wpforms[fields][8][state]\" value=\"NSW\" aria-errormessage=\"wpforms-323-field_8-state-error\" required><label for=\"wpforms-323-field_8-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-323-field_8-postal\" class=\"wpforms-field-address-postal wpforms-field-required\" name=\"wpforms[fields][8][postal]\" aria-errormessage=\"wpforms-323-field_8-postal-error\" required><label for=\"wpforms-323-field_8-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-323-field_9-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-323-field_9\">Patient&#039;s Date of Birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-323-field_9\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][9][date]\" aria-errormessage=\"wpforms-323-field_9-error\" aria-describedby=\"wpforms-323-field_9-description\" 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 id=\"wpforms-323-field_9-description\" class=\"wpforms-field-description\">Date of birth<\/div><\/div><div id=\"wpforms-323-field_10-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-323-field_10\">Patient&#039;s Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-323-field_10\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][10]\" aria-label=\"Patient&#039;s Phone\" aria-errormessage=\"wpforms-323-field_10-error\" aria-describedby=\"wpforms-323-field_10-description\" required><div id=\"wpforms-323-field_10-description\" class=\"wpforms-field-description\">Mobile phone number<\/div><\/div><div id=\"wpforms-323-field_11-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-323-field_11\">Patient&#039;s Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-323-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" spellcheck=\"false\" aria-errormessage=\"wpforms-323-field_11-error\" aria-describedby=\"wpforms-323-field_11-description\" required><div id=\"wpforms-323-field_11-description\" class=\"wpforms-field-description\">Email address<\/div><\/div><div id=\"wpforms-323-field_12-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"12\"><h3 id=\"wpforms-323-field_12\" aria-errormessage=\"wpforms-323-field_12-error\">PRACTICE DETAILS<\/h3><\/div><div id=\"wpforms-323-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-323-field_14\">Practice Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-323-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-323-field_14-error\" required><\/div><div id=\"wpforms-323-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-323-field_15\">Practitioner <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-323-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-323-field_15-error\" aria-describedby=\"wpforms-323-field_15-description\" required><div id=\"wpforms-323-field_15-description\" class=\"wpforms-field-description\">Practitioner performing the procedure for the patient<\/div><\/div><div id=\"wpforms-323-field_16-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"16\"><h3 id=\"wpforms-323-field_16\" aria-errormessage=\"wpforms-323-field_16-error\">TREATMENT<\/h3><\/div><div id=\"wpforms-323-field_17-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-type=\"checkbox\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">Proposed Treatement <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-323-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Extractions\" aria-errormessage=\"wpforms-323-field_17_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_1\">Extractions<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_2\" name=\"wpforms[fields][17][]\" value=\"Implants\" aria-errormessage=\"wpforms-323-field_17_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_2\">Implants<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Restorations\" aria-errormessage=\"wpforms-323-field_17_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_3\">Restorations<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_4\" name=\"wpforms[fields][17][]\" value=\"Scale &amp; Clean\" aria-errormessage=\"wpforms-323-field_17_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_4\">Scale &amp; Clean<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_5\" name=\"wpforms[fields][17][]\" value=\"Periodontal\" aria-errormessage=\"wpforms-323-field_17_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_5\">Periodontal<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_6\" name=\"wpforms[fields][17][]\" value=\"Impressions\" aria-errormessage=\"wpforms-323-field_17_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_6\">Impressions<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_7\" name=\"wpforms[fields][17][]\" value=\"Crown \/ Bridge\" aria-errormessage=\"wpforms-323-field_17_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_7\">Crown \/ Bridge<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_17_8\" name=\"wpforms[fields][17][]\" value=\"Other\" aria-errormessage=\"wpforms-323-field_17_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_17_8\">Other<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-323-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"29\"><fieldset><legend class=\"wpforms-field-label\">Expected Treatment Duration <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-323-field_29\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_29_1\" name=\"wpforms[fields][29][]\" value=\"1h\" aria-errormessage=\"wpforms-323-field_29_1-error\" aria-describedby=\"wpforms-323-field_29-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_29_1\">1h<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_29_2\" name=\"wpforms[fields][29][]\" value=\"1.5h\" aria-errormessage=\"wpforms-323-field_29_2-error\" aria-describedby=\"wpforms-323-field_29-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_29_2\">1.5h<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_29_3\" name=\"wpforms[fields][29][]\" value=\"2h\" aria-errormessage=\"wpforms-323-field_29_3-error\" aria-describedby=\"wpforms-323-field_29-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_29_3\">2h<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_29_4\" name=\"wpforms[fields][29][]\" value=\"2.5h\" aria-errormessage=\"wpforms-323-field_29_4-error\" aria-describedby=\"wpforms-323-field_29-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_29_4\">2.5h<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_29_6\" name=\"wpforms[fields][29][]\" value=\"3h\" aria-errormessage=\"wpforms-323-field_29_6-error\" aria-describedby=\"wpforms-323-field_29-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_29_6\">3h<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_29_7\" name=\"wpforms[fields][29][]\" value=\"3.5h\" aria-errormessage=\"wpforms-323-field_29_7-error\" aria-describedby=\"wpforms-323-field_29-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_29_7\">3.5h<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_29_8\" name=\"wpforms[fields][29][]\" value=\"&gt;3.5h\" aria-errormessage=\"wpforms-323-field_29_8-error\" aria-describedby=\"wpforms-323-field_29-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_29_8\">&gt;3.5h<\/label><\/li><\/ul><div id=\"wpforms-323-field_29-description\" class=\"wpforms-field-description\">Please note. Patient will be invoiced according to the expected treatment duration.<\/div><\/fieldset><\/div><div id=\"wpforms-323-field_22-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"22\"><h3 id=\"wpforms-323-field_22\" aria-errormessage=\"wpforms-323-field_22-error\">INFORMATION<\/h3><\/div><div id=\"wpforms-323-field_23-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label\">Sedation information provided to patient <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-323-field_23\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_23_1\" name=\"wpforms[fields][23][]\" value=\"Completed\" aria-errormessage=\"wpforms-323-field_23_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_23_1\">Completed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-323-field_24-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Sedation Instructions provided to patient <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-323-field_24\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_24_1\" name=\"wpforms[fields][24][]\" value=\"Completed\" aria-errormessage=\"wpforms-323-field_24_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_24_1\">Completed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-323-field_25-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"25\"><fieldset><legend class=\"wpforms-field-label\">Sedation pricing discussed with patient <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-323-field_25\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_25_1\" name=\"wpforms[fields][25][]\" value=\"Completed\" aria-errormessage=\"wpforms-323-field_25_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_25_1\">Completed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-323-field_26-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"26\"><fieldset><legend class=\"wpforms-field-label\">Sedation written consent obtained <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-323-field_26\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_26_1\" name=\"wpforms[fields][26][]\" value=\"Completed\" aria-errormessage=\"wpforms-323-field_26_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_26_1\">Completed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-323-field_27-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-type=\"checkbox\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Online medical history link provided to patient to complete <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-323-field_27\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-323-field_27_1\" name=\"wpforms[fields][27][]\" value=\"Completed\" aria-errormessage=\"wpforms-323-field_27_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-323-field_27_1\">Completed<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-323-field_18-container\" class=\"wpforms-field wpforms-field-divider\" data-field-type=\"divider\" data-field-id=\"18\"><h3 id=\"wpforms-323-field_18\" aria-errormessage=\"wpforms-323-field_18-error\" aria-describedby=\"wpforms-323-field_18-description\">APPOINTMENT<\/h3><div id=\"wpforms-323-field_18-description\" class=\"wpforms-field-description\">Appointment details<\/div><\/div><div id=\"wpforms-323-field_19-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"19\"><fieldset><legend class=\"wpforms-field-label\">Appointment 1 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-323-field_19\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][19][date]\" aria-errormessage=\"wpforms-323-field_19-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><label for=\"wpforms-323-field_19\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-323-field_19-time\" class=\"wpforms-field-date-time-time wpforms-timepicker wpforms-field-required\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" data-min-time=\"08:00am\" data-max-time=\"06:00pm\" data-rule-time-limit=\"true\" name=\"wpforms[fields][19][time]\" aria-errormessage=\"wpforms-323-field_19-time-error\" required><label for=\"wpforms-323-field_19-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-323-field_21-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"21\"><fieldset><legend class=\"wpforms-field-label\">Appointment 2<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-323-field_21\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][21][date]\" aria-errormessage=\"wpforms-323-field_21-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-323-field_21\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-323-field_21-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" data-min-time=\"08:00am\" data-max-time=\"06:00pm\" data-rule-time-limit=\"true\" name=\"wpforms[fields][21][time]\" aria-errormessage=\"wpforms-323-field_21-time-error\" ><label for=\"wpforms-323-field_21-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-323-field_20-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-type=\"date-time\" data-field-id=\"20\"><fieldset><legend class=\"wpforms-field-label\">Appointment 3<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-date-type-datepicker\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-323-field_20\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"1\" data-disable-todays-date=\"0\" data-input=\"true\" name=\"wpforms[fields][20][date]\" aria-errormessage=\"wpforms-323-field_20-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-323-field_20\" class=\"wpforms-field-sublabel after\">Date<\/label><\/div><div class=\"wpforms-field-row-block\"><input type=\"text\" id=\"wpforms-323-field_20-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-time-format=\"g:i A\" data-step=\"30\" data-rule-time12h=\"true\" data-min-time=\"08:00am\" data-max-time=\"06:00pm\" data-rule-time-limit=\"true\" name=\"wpforms[fields][20][time]\" aria-errormessage=\"wpforms-323-field_20-time-error\" ><label for=\"wpforms-323-field_20-time\" class=\"wpforms-field-sublabel after\">Time<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-323-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-type=\"text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-323-field_30\">Name of person completing this form <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-323-field_30\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][30]\" aria-errormessage=\"wpforms-323-field_30-error\" required><\/div><\/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=\"323\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/354\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-323\" class=\"wpforms-submit\" data-alt-text=\"Sending\u2026\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img decoding=\"async\" src=\"https:\/\/dentalsedation.website\/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\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>Please enable JavaScript in your browser to complete this form. PATIENT&#039;S DETAILS Patient&#039;s Name *FirstLastPatient&#039;s Address *Address Line 1Address Line 2CityState \/ Province \/ RegionPostal CodePatient&#039;s Date of Birth *Date of birthPatient&#039;s Phone *Mobile phone numberPatient&#039;s Email *Email address PRACTICE DETAILS Practice Name *Practitioner *Practitioner performing the procedure for the patient TREATMENT Proposed Treatement * [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-354","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/354","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/comments?post=354"}],"version-history":[{"count":10,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/354\/revisions"}],"predecessor-version":[{"id":683,"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/pages\/354\/revisions\/683"}],"wp:attachment":[{"href":"https:\/\/dentalsedation.website\/index.php\/wp-json\/wp\/v2\/media?parent=354"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}