{"id":2698,"date":"2024-12-18T06:10:25","date_gmt":"2024-12-18T06:10:25","guid":{"rendered":"https:\/\/enfolytics.com\/alphadental\/?page_id=2698"},"modified":"2024-12-20T10:43:23","modified_gmt":"2024-12-20T10:43:23","slug":"schedule-a-referral-consultation","status":"publish","type":"page","link":"https:\/\/enfolytics.com\/alphadental\/schedule-a-referral-consultation\/","title":{"rendered":"Schedule a Referral Consultation"},"content":{"rendered":"\n<div class=\"referral-consult-forms\">\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2253-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2253\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/alphadental\/wp-json\/wp\/v2\/pages\/2698#wpcf7-f2253-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2253\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.4\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2253-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:2253,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-185&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-284&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-1&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;checkbox-559&quot;,&quot;operator&quot;:&quot;is empty&quot;,&quot;if_value&quot;:&quot;&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:&quot;200&quot;,&quot;animation_outtime&quot;:&quot;200&quot;,&quot;conditions_ui&quot;:&quot;text_only&quot;,&quot;notice_dismissed&quot;:&quot;&quot;}}\" \/>\n<\/div>\n<div class=\"location-dropdown1 form-group\">\n\t<lable>Choose the location you wish to get a consultation at:\n\t<\/lable>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Patientselect-465\"><select class=\"wpcf7-form-control wpcf7-select location-select\" aria-invalid=\"false\" name=\"Patientselect-465\"><option value=\"CHOOSE LOCATION\">CHOOSE LOCATION<\/option><option value=\"WEST COLUMBUS\">WEST COLUMBUS<\/option><option value=\"LOGAN\">LOGAN<\/option><option value=\"ASHLAND\">ASHLAND<\/option><option value=\"EAST COLUMBUS\">EAST COLUMBUS<\/option><option value=\"ZANESVILLE\">ZANESVILLE<\/option><option value=\"MARION\">MARION<\/option><option value=\"SPRINGFIELD\">SPRINGFIELD<\/option><option value=\"AKRON\">AKRON<\/option><option value=\"DAYTON\">DAYTON<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"consentform form-group\" style=\"display:none;\">\n\t<div class=\"row\">\n\t\t<div class=\"col-md-4 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Patient's First Name:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PatientFullName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Full Name\" value=\"\" type=\"text\" name=\"PatientFullName\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-4 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Patient's Last Name:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PatientlastName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Patient&#039;s Last Name\" value=\"\" type=\"text\" name=\"PatientlastName\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-4 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Patient's DOB:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Patientdate-300\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"MM\/DD\/YYYY\" value=\"\" type=\"date\" name=\"Patientdate-300\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-4 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group wpcf7-tel\">\n\t\t\t\t<p><label>Patient's Mobile Phone #:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PatientPhone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone#\" value=\"\" type=\"tel\" name=\"PatientPhone\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-4 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Email address:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Patientemail-770\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"Patientemail-770\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-4 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Name of Patient's Insurance:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Patient-Insurance\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of Patient&#039;s Insurance\" value=\"\" type=\"text\" name=\"Patient-Insurance\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Insurance ID #:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Insurance_ID\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Insurance ID #\" value=\"\" type=\"text\" name=\"Insurance_ID\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Is this a State Funded Medicaid Insurance? <\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-283\"><span class=\"wpcf7-form-control wpcf7-radio form-control\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-283\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-283\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-283\" value=\"Unsure\" \/><span class=\"wpcf7-list-item-label\">Unsure<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 col-sm-12 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>Do you have a secondary insurance?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-284\"><span class=\"wpcf7-form-control wpcf7-radio form-control\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-284\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-284\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<div data-id=\"group-185\" data-orig_data_id=\"group-185\"  data-class=\"wpcf7cf_group\">\n\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t<p><label>Name of PPO insurance.<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PPOName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of PPO insurance\" value=\"\" type=\"text\" name=\"PPOName\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t<p><label>Group or Client #<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Client\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Group or Client #\" value=\"\" type=\"text\" name=\"Client\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t<p><label> Subscriber ID # {optional field}<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"SubscriberID\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Subscriber ID #\" value=\"\" type=\"text\" name=\"SubscriberID\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t<p><label>Telephone # for insurance (can be found on the back of the card)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insurancephone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Telephone # for insurance\" value=\"\" type=\"text\" name=\"insurancephone\" \/><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t<div class=\"col-md-12 col-sm-12 col-xs-12\">\n\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t<p><label>Name of subscriber ID:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-559\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-559[]\" value=\"Self\" \/><span class=\"wpcf7-list-item-label\">Self<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div data-id=\"group-1\" data-orig_data_id=\"group-1\"  data-class=\"wpcf7cf_group\">\n\t\t\t\t\t\t<div class=\"row\">\n\t\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t\t<p><label>Subscriber first name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Subscriberfirstname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subscriber first name\" value=\"\" type=\"text\" name=\"Subscriberfirstname\" \/><\/span>\n\t\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t\t<p><label>Subscriber last name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Subscriberlastname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subscriber last name\" value=\"\" type=\"text\" name=\"Subscriberlastname\" \/><\/span>\n\t\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t\t<p><label>Subscriber DOB<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"SubscriberDOB\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subscriber DOB\" value=\"\" type=\"date\" name=\"SubscriberDOB\" \/><\/span>\n\t\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t\t\t\t<p><label>Subscriber SSN<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"SubscriberSSN\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Subscriber SSN\" value=\"\" type=\"text\" name=\"SubscriberSSN\" \/><\/span>\n\t\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n<!-- <\/div> -->\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 col-sm-12 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label class=\"referalchecklist-title\">Referred for:<\/label>\n\t\t\t\t<\/p>\n\t\t\t\t<div class=\"referalchecklist\">\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-707\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-707[]\" value=\"Extractions\" \/><span class=\"wpcf7-list-item-label\">Extractions<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-708\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-708[]\" value=\"Wisdom Teeth Extractions\" \/><span class=\"wpcf7-list-item-label\">Wisdom Teeth Extractions<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-709\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-709[]\" value=\"Root Canal\" \/><span class=\"wpcf7-list-item-label\">Root Canal<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-710\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-710[]\" value=\"Crowns\/Bridges\" \/><span class=\"wpcf7-list-item-label\">Crowns\/Bridges<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-711\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-711[]\" value=\"Deep Cleaning\" \/><span class=\"wpcf7-list-item-label\">Deep Cleaning<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-712\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-712[]\" value=\"Comprehensive Exam\" \/><span class=\"wpcf7-list-item-label\">Comprehensive Exam<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-713\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-713[]\" value=\"Fillings\" \/><span class=\"wpcf7-list-item-label\">Fillings<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-714\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-714[]\" value=\"Implants\/Implant restoration\" \/><span class=\"wpcf7-list-item-label\">Implants\/Implant restoration<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"referral-check\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-715\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-715[]\" value=\"Dentures\/Partials\" \/><span class=\"wpcf7-list-item-label\">Dentures\/Partials<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"row cfselect-row\">\n\t\t<div class=\"cfbottom-blck mt-0\">\n\t\t\t<div class=\"row gy-3\">\n\t\t\t\t<div class=\"col-md-6 referral-files\">\n\t\t\t\t\t<p><label>Upload your Referral:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Patientmfile-257\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" multiple=\"multiple\" data-name=\"Patientmfile-257\" data-type=\"jpg|jpeg|png|pdf|doc|mp4|tiff|docx\" data-limit=\"20971520\" data-max=\"5\" data-id=\"2253\" data-version=\"free version 1.3.8.5\" accept=\".jpg, .jpeg, .png, .pdf, .doc, .mp4, .tiff, .docx\" \/><\/span><br \/>\n(However Many Pages)\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-md-6 xray-files\">\n\t\t\t\t\t<p><label>Upload X-ray(Optional):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Patientmfile-248\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" aria-invalid=\"false\" type=\"file\" multiple=\"multiple\" data-name=\"Patientmfile-248\" data-type=\"jpg|jpeg|png|pdf|doc|docx\" data-limit=\"20971520\" data-max=\"5\" data-id=\"2253\" data-version=\"free version 1.3.8.5\" accept=\".jpg, .jpeg, .png, .pdf, .doc, .docx\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-6 col-sm-6 col-xs-12\">\n\t\t\t<div class=\"form-group\">\n\t\t\t\t<p><label>What time of the day do you prefer your consultation to be?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"select-76\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"select-76\"><option value=\"Morning\">Morning<\/option><option value=\"Noon\">Noon<\/option><option value=\"Afternoon\">Afternoon<\/option><option value=\"Anytime\">Anytime<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<div class=\"col-md-12 col-sm-12 col-xs-12 pagebooksubmitbar\">\n\t\t\t<div class=\"form-group\">\n\t\t\t<\/div>\n\t\t\t<div>\n\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t<p><button class=\"button\" type=\"submit\">Submit<\/button>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"template-parts\/default-template.php","meta":{"footnotes":""},"class_list":["post-2698","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/pages\/2698","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/comments?post=2698"}],"version-history":[{"count":4,"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/pages\/2698\/revisions"}],"predecessor-version":[{"id":2798,"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/pages\/2698\/revisions\/2798"}],"wp:attachment":[{"href":"https:\/\/enfolytics.com\/alphadental\/wp-json\/wp\/v2\/media?parent=2698"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}