{"id":3288,"date":"2022-08-16T16:52:40","date_gmt":"2022-08-16T16:52:40","guid":{"rendered":"https:\/\/orthoduplateau.com\/refer-a-patient\/"},"modified":"2022-09-28T12:11:11","modified_gmt":"2022-09-28T12:11:11","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/orthoduplateau.com\/en\/refer-a-patient\/","title":{"rendered":"Refer a patient"},"content":{"rendered":"<section id=\"bt_bb_section69e54dbfd44db\" class=\"bt_bb_section bt_bb_layout_boxed_1200\"  data-bt-override-class=\"null\"><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row_wrapper\"><div  class=\"bt_bb_row\"  data-bt-override-class=\"{}\"><div  class=\"bt_bb_column col-xxl-12 col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_vertical_align_top bt_bb_align_left bt_bb_padding_normal\"  data-width=\"12\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_medium\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_medium&quot;,&quot;xxl&quot;:&quot;medium&quot;,&quot;xl&quot;:&quot;medium&quot;}}\"><\/div><header class=\"bt_bb_headline bt_bb_dash_none bt_bb_size_inherit bt_bb_align_inherit bt_bb_dash_type_none\" style=\";color:rgb(122,191,179);border-color:rgb(122,191,179);\" data-bt-override-class=\"{&quot;bt_bb_size_&quot;:{&quot;current_class&quot;:&quot;bt_bb_size_inherit&quot;,&quot;xxl&quot;:&quot;inherit&quot;,&quot;xl&quot;:&quot;inherit&quot;},&quot;bt_bb_align_&quot;:{&quot;current_class&quot;:&quot;bt_bb_align_inherit&quot;,&quot;xxl&quot;:&quot;inherit&quot;,&quot;xl&quot;:&quot;inherit&quot;}}\"><h1 class=\"bt_bb_headline_tag\"><span class=\"bt_bb_headline_content\"><span>Form | Refer a patient<\/span><\/span><\/h1><\/header><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_small\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_small&quot;,&quot;xxl&quot;:&quot;small&quot;,&quot;xl&quot;:&quot;small&quot;}}\"><\/div><div  class=\"bt_bb_text\" style=\"font-size: 18px\"><p><strong>Form for dentists.<\/strong><\/p>\n<\/div><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_small\" data-bt-override-class=\"{&quot;bt_bb_top_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_top_spacing_none&quot;,&quot;xxl&quot;:&quot;none&quot;,&quot;xl&quot;:&quot;none&quot;},&quot;bt_bb_bottom_spacing_&quot;:{&quot;current_class&quot;:&quot;bt_bb_bottom_spacing_small&quot;,&quot;xxl&quot;:&quot;small&quot;,&quot;xl&quot;:&quot;small&quot;}}\"><\/div><div class=\"bt_bb_contact_form_7\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3311-o1\" lang=\"en-CA\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/3288#wpcf7-f3311-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"3311\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.7.7\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_CA\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3311-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p>Patient information:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"FirstName\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name*\" value=\"\" type=\"text\" name=\"FirstName\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"LastName\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name*\" value=\"\" type=\"text\" name=\"LastName\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"DateofBirth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of birth*\" value=\"\" type=\"date\" name=\"DateofBirth\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ParentNameifapplicable\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name of parent (if applicable)\" value=\"\" type=\"text\" name=\"ParentNameifapplicable\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Telephone*\" value=\"\" type=\"tel\" name=\"Phone\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Courrieldupatient\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" placeholder=\"Patient Email\" value=\"\" type=\"email\" name=\"Courrieldupatient\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ContactPatient\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"ContactPatient\" value=\"Please call patient\" \/><span class=\"wpcf7-list-item-label\">Please call patient<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"ContactPatient\" value=\"Patient will call\" \/><span class=\"wpcf7-list-item-label\">Patient will call<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Reason for referral:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"RaisonReference\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Crowding\" \/><span class=\"wpcf7-list-item-label\">Crowding<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Excess space\" \/><span class=\"wpcf7-list-item-label\">Excess space<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Missing teeth\" \/><span class=\"wpcf7-list-item-label\">Missing teeth<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Impacted teeth\" \/><span class=\"wpcf7-list-item-label\">Impacted teeth<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Crossbite\" \/><span class=\"wpcf7-list-item-label\">Crossbite<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Oral habits\" \/><span class=\"wpcf7-list-item-label\">Oral habits<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Overjet\" \/><span class=\"wpcf7-list-item-label\">Overjet<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Class II\" \/><span class=\"wpcf7-list-item-label\">Class II<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Classe III\" \/><span class=\"wpcf7-list-item-label\">Classe III<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Overbite\" \/><span class=\"wpcf7-list-item-label\">Overbite<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Pre-prosthodontic ortho\" \/><span class=\"wpcf7-list-item-label\">Pre-prosthodontic ortho<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"RaisonReference[]\" value=\"Orthognathic surgery\" \/><span class=\"wpcf7-list-item-label\">Orthognathic surgery<\/span><\/span><\/span><\/span>\n<\/p>\n<p>Radiographs:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"radiographies\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"radiographies\"><option value=\"Attached to this form\">Attached to this form<\/option><option value=\"Sent by email to info@orthoduplateau.com\">Sent by email to info@orthoduplateau.com<\/option><option value=\"Given to patient\">Given to patient<\/option><option value=\"None\">None<\/option><\/select><\/span>\n<\/p>\n<p>Imaging (radiographs, photos) | Formats .jpg, .pdf, .txt:\n<\/p>\n<p><div id=\"mfcf7_zl_multifilecontainer\"><span class=\"mfcf7-zl-multiline-sample\" style=\"display:none\"><p class=\"wpcf7-form-control-wrap Fichierjoint\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multilinefile\" multiple=\"multiple\" value=\"Choisir Fichier(s)\" aria-invalid=\"false\" type=\"file\" name=\"Fichierjoint[]\" \/> <span class=\"mfcf7-zl-multifile-name\"><\/span><a href=\"javascript:void(0);\" class=\"mfcf7_zl_delete_file\"><span class=\"delete-file\" aria-hidden=\"true\">&#x274C;<\/span><\/a><\/p><\/span><\/div><span class=\"wpcf7-form-control-wrap zl-form-control-wrap Fichierjoint\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multilinefile\" multiple=\"multiple\" value=\"Choisir Fichier(s)\" aria-invalid=\"false\" type=\"file\" name=\"Fichierjoint[]\" \/> <span class=\"mfcf7-zl-multifile-name\"><\/span><a href=\"javascript:void(0);\" class=\"mfcf7_zl_delete_file\"><span class=\"delete-file\" aria-hidden=\"true\">&#x274C;<\/span><\/a><\/span><p><label><span class=\"wpcf7-form-control-wrap\" data-name=\"Fichierjoint-zl-mfcf7-upld-btn\"><input type=\"button\" name=\"Fichierjoint-zl-mfcf7-upld-btn\" class=\"button button-primary qbutton\" id=\"mfcf7_zl_add_file\" value=\"Choisir Fichier(s)\"><\/span><\/label><\/p>\n<\/p>\n<p>Date of radiograph:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" placeholder=\"Date\" value=\"\" type=\"date\" name=\"date\" \/><\/span>\n<\/p>\n<p>Name of referring dentist:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Nomdudentisterfrant\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name of referring dentist*\" value=\"\" type=\"text\" name=\"Nomdudentisterfrant\" \/><\/span>\n<\/p>\n<p>Email of referring dentist:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"email-997\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email*\" value=\"\" type=\"email\" name=\"email-997\" \/><\/span>\n<\/p>\n<p>Additional information:\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"textarea\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"textarea\"><\/textarea><\/span>\n<\/p>\n<p><div id=\"cf7sr-69e54dbfd6e12\" class=\"cf7sr-g-hcaptcha\" data-theme=\"light\" data-size=\"normal\" data-sitekey=\"cb0ef2c8-d66c-456e-821e-bc5ebc064088\"><\/div><span class=\"wpcf7-form-control-wrap cf7sr-hcaptcha\" data-name=\"cf7sr-hcaptcha\"><input type=\"hidden\" name=\"cf7sr-hcaptcha\" value=\"\" class=\"wpcf7-form-control\"><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control has-spinner wpcf7-submit\" id=\"SoumettreSubmit\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div><div class=\"bt_bb_separator bt_bb_border_style_none bt_bb_top_spacing_none bt_bb_bottom_spacing_normal\" 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