{"id":1559,"date":"2018-11-09T14:59:44","date_gmt":"2018-11-09T14:59:44","guid":{"rendered":"http:\/\/176.32.230.11\/springhilldental.co.uk\/?page_id=1559"},"modified":"2018-12-04T11:07:21","modified_gmt":"2018-12-04T11:07:21","slug":"referrals","status":"publish","type":"page","link":"http:\/\/176.32.230.11\/springhilldental.co.uk\/referrals\/","title":{"rendered":"Referrals"},"content":{"rendered":"<p>&nbsp;<\/p>\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f1671-o1\" lang=\"en-GB\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/springhilldental.co.uk\/wp-json\/wp\/v2\/pages\/1559#wpcf7-f1671-o1\" method=\"post\" class=\"wpcf7-form init\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1671\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.3.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_GB\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1671-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<h2> Dental Surgeon Detail<\/h2>\n<p> Referring Dental Surgeon<br \/>\n<span class=\"wpcf7-form-control-wrap ReferringDentalSurgeon\"><input type=\"text\" name=\"ReferringDentalSurgeon\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Practice<br \/>\n<span class=\"wpcf7-form-control-wrap Practice\"><input type=\"text\" name=\"Practice\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Address<br \/>\n<span class=\"wpcf7-form-control-wrap Address\"><textarea name=\"Address\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span><br \/>\n Postcode<br \/>\n<span class=\"wpcf7-form-control-wrap Postcode\"><input type=\"text\" name=\"Postcode\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Telephone No.<br \/>\n<span class=\"wpcf7-form-control-wrap PracticeTelephoneNo\"><input type=\"tel\" name=\"PracticeTelephoneNo.\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span><br \/>\nEmail<br \/>\n    <span class=\"wpcf7-form-control-wrap your-email\"><input type=\"email\" name=\"your-email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/p>\n<h2> Patient Details<\/h2>\n<p> Patient Name<br \/>\n<span class=\"wpcf7-form-control-wrap PatientName\"><input type=\"text\" name=\"PatientName\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Title<br \/>\n<span class=\"wpcf7-form-control-wrap Title\"><input type=\"text\" name=\"Title\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n DOB<br \/>\n<span class=\"wpcf7-form-control-wrap DOB\"><input type=\"text\" name=\"DOB\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Address<br \/>\n<span class=\"wpcf7-form-control-wrap PatientAddress\"><textarea name=\"PatientAddress\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span><br \/>\n Postcode<br \/>\n<span class=\"wpcf7-form-control-wrap PatientPostcode\"><input type=\"text\" name=\"PatientPostcode\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Telephone(Home)<br \/>\n<span class=\"wpcf7-form-control-wrap TelephoneHome\"><input type=\"tel\" name=\"TelephoneHome\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Telephone(Work)<br \/>\n<span class=\"wpcf7-form-control-wrap TelephoneWork\"><input type=\"tel\" name=\"TelephoneWork\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Mobile<br \/>\n<span class=\"wpcf7-form-control-wrap Mobile\"><input type=\"tel\" name=\"Mobile\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n Email<br \/>\n<span class=\"wpcf7-form-control-wrap Patientemail\"><input type=\"email\" name=\"Patientemail\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><br \/>\n Have we seen this patient before?<br \/>\n<span class=\"wpcf7-form-control-wrap SeenpatientBefore\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"SeenpatientBefore\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"SeenpatientBefore\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\nWould your patient like contact via email?<br \/>\n<span class=\"wpcf7-form-control-wrap patientlikecontactviaemail\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"patientlikecontactviaemail\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"patientlikecontactviaemail\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label><\/p>\n<p>Referral Type<br \/>\n<span class=\"wpcf7-form-control-wrap ReferralType\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"ReferralType[]\" value=\"Endodontic*\" \/><span class=\"wpcf7-list-item-label\">Endodontic*<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ReferralType[]\" value=\"Periodontal\" \/><span class=\"wpcf7-list-item-label\">Periodontal<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ReferralType[]\" value=\"Restorative\" \/><span class=\"wpcf7-list-item-label\">Restorative<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"ReferralType[]\" value=\"Orthodontic\" \/><span class=\"wpcf7-list-item-label\">Orthodontic<\/span><\/span><\/span><\/span><br \/>\nReason for Referral<br \/>\n<span class=\"wpcf7-form-control-wrap ReasonforReferral\"><textarea name=\"ReasonforReferral\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/p>\n<p><storng>*For Endodontic Referrals<\/strong><br \/>\n Tooth number(s)<br \/>\n<span class=\"wpcf7-form-control-wrap Toothnumbers\"><input type=\"text\" name=\"Toothnumbers\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n Do you wish us to do the post and core if one is required?<br \/>\n<span class=\"wpcf7-form-control-wrap Doyouwishustodothepostandcoreifoneisrequired\"><input type=\"text\" name=\"Doyouwishustodothepostandcoreifoneisrequired\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><br \/>\n Pain<br \/>\n<span class=\"wpcf7-form-control-wrap Pain\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"Pain\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"Pain\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\n If Yes<br \/>\n<span class=\"wpcf7-form-control-wrap PainIfYes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"PainIfYes[]\" value=\"Severe\" \/><span class=\"wpcf7-list-item-label\">Severe<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"PainIfYes[]\" value=\"Moderate\" \/><span class=\"wpcf7-list-item-label\">Moderate<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"PainIfYes[]\" value=\"Mild\" \/><span class=\"wpcf7-list-item-label\">Mild<\/span><\/span><\/span><\/span><br \/>\n Swelling<br \/>\n<span class=\"wpcf7-form-control-wrap Swelling\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"Swelling\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"Swelling\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><br \/>\n Tooth Previously root treated<br \/>\n<span class=\"wpcf7-form-control-wrap ToothPreviouslyroottreated\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"ToothPreviouslyroottreated[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ToothPreviouslyroottreated[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ToothPreviouslyroottreated[]\" value=\"Consultation only\" \/><span class=\"wpcf7-list-item-label\">Consultation only<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"ToothPreviouslyroottreated[]\" value=\"Treatment\" \/><span class=\"wpcf7-list-item-label\">Treatment<\/span><\/span><\/span><\/span><br \/>\n Radiographs attached (10mb limit)<br \/>\n<span class=\"wpcf7-form-control-wrap Radiographsattached\"><input type=\"file\" name=\"Radiographsattached\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><input type=\"submit\" value=\"Send\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":""},"_links":{"self":[{"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/pages\/1559"}],"collection":[{"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/comments?post=1559"}],"version-history":[{"count":3,"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/pages\/1559\/revisions"}],"predecessor-version":[{"id":1715,"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/pages\/1559\/revisions\/1715"}],"wp:attachment":[{"href":"http:\/\/176.32.230.11\/springhilldental.co.uk\/wp-json\/wp\/v2\/media?parent=1559"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}