{"id":13,"date":"2015-12-14T04:12:01","date_gmt":"2015-12-14T04:12:01","guid":{"rendered":"http:\/\/theme-fusion.com\/avada\/medical\/?page_id=13"},"modified":"2015-12-14T04:12:01","modified_gmt":"2015-12-14T04:12:01","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/endoperiogroup.com\/refer-a-patient\/","title":{"rendered":"Refer A Patient"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-one\"><h1 class=\"fusion-title-heading title-heading-center\" style=\"margin:0;\"><h1>REFER A PATIENT<\/h1><\/h1><\/div><div class=\"fusion-text fusion-text-1\"><p style=\"text-align: center;\"><strong>Please note that we only accept patient referrals from doctors.<\/strong><\/p>\n<p style=\"text-align: center;\">If you are a patient requesting a referral on behalf of yourself, please see your doctor before filling out this form. Contact us at <a href=\"mailto:admin@endoperiogroup.com\">admin@endoperiogroup.com<\/a><\/p>\n<\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-1 fusion-button-span-no fusion-button-default-type\" target=\"_self\" href=\"https:\/\/endoperiogroup.com\/wp-content\/uploads\/2021\/06\/Endo-Perio-Group-REFERRAL-FORM-Letter-Size.jpg\"><span class=\"fusion-button-text\">Download Printable Form<\/span><\/a><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-2 fusion-sep-none fusion-title-text fusion-title-size-one\"><h1 class=\"fusion-title-heading title-heading-left\" style=\"margin:0;\"><h2>Or fill out the online form below<\/h2><\/h1><\/div><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-1089 has-icon-alignment\" style=\"--awb-tooltip-text-color:#ffffff;--awb-tooltip-background-color:#333333;--awb-form-placeholder-color:rgba(0,0,0,0.5);--awb-form-text-color:#000000;--awb-form-border-width-top:0px;--awb-form-border-width-bottom:2px;--awb-form-border-width-right:0px;--awb-form-border-width-left:0px;--awb-form-focus-border-color:#5b4ad4;--awb-form-focus-border-hover-color:rgba(91,74,212,0.5);--awb-icon-alignment-top:0px;--awb-icon-alignment-bottom:2px;--awb-icon-alignment-font-size:1em;\" data-form-id=\"1089\" data-config=\"{&quot;form_id&quot;:&quot;1089&quot;,&quot;form_post_id&quot;:&quot;1089&quot;,&quot;post_id&quot;:13,&quot;form_type&quot;:&quot;ajax&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;i_am_a_doctor_referring_a_patient&quot;:&quot;I am a doctor referring a patient&quot;,&quot;first_name&quot;:&quot;&quot;,&quot;last_name&quot;:&quot;&quot;,&quot;dob&quot;:&quot;&quot;,&quot;medical_alert&quot;:&quot;&quot;,&quot;address_1&quot;:&quot;&quot;,&quot;address_2&quot;:&quot;&quot;,&quot;postal-code&quot;:&quot;&quot;,&quot;&quot;:&quot;&quot;,&quot;postal_code&quot;:&quot;&quot;,&quot;phone_number&quot;:&quot;&quot;,&quot;x-rays_enclosed&quot;:&quot;X-rays enclosed&quot;,&quot;Exo if RCT unrestorable?:&quot;:&quot;Exo if RCT unrestorable?:&quot;,&quot;RCT Final Filling by Dr. Campbell?: \\u25cb&quot;:&quot;RCT Final Filling by Dr. Campbell?:&quot;,&quot;relevant_information&quot;:&quot;Relevant Information&quot;,&quot;periodontal_therapy:&quot;:&quot;Periodontal Therapy:&quot;,&quot;referring_doctor&quot;:&quot;Referring Doctor&quot;,&quot;remarks&quot;:&quot;Remarks&quot;,&quot;Please send us a referral pad&quot;:&quot;&quot;,&quot;Insured&quot;:&quot;&quot;,&quot;carrier&quot;:&quot;&quot;,&quot;employer&quot;:&quot;&quot;,&quot;grouppolicy&quot;:&quot;&quot;,&quot;id_sin&quot;:&quot;&quot;,&quot;Division&quot;:&quot;&quot;,&quot;Department&quot;:&quot;&quot;},&quot;field_logics&quot;:{&quot;i_am_a_doctor_referring_a_patient&quot;:&quot;&quot;,&quot;first_name&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;last_name&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;dob&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;medical_alert&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;address_1&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;address_2&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;postal-code&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;postal_code&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;phone_number&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;x-rays_enclosed&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;Exo if RCT unrestorable?:&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;RCT Final Filling by Dr. Campbell?: \\u25cb&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;relevant_information&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;periodontal_therapy:&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;referring_doctor&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;remarks&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;Please send us a referral pad&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;Insured&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;carrier&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;employer&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;grouppolicy&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;id_sin&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;Division&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;,&quot;Department&quot;:&quot;[{\\&quot;operator\\&quot;:\\&quot;and\\&quot;,\\&quot;comparison\\&quot;:\\&quot;equal\\&quot;,\\&quot;field\\&quot;:\\&quot;i_am_a_doctor_referring_a_patient\\&quot;,\\&quot;value\\&quot;:\\&quot;Yes\\&quot;}]&quot;},&quot;field_types&quot;:{&quot;i_am_a_doctor_referring_a_patient&quot;:&quot;radio&quot;,&quot;first_name&quot;:&quot;text&quot;,&quot;last_name&quot;:&quot;text&quot;,&quot;dob&quot;:&quot;text&quot;,&quot;medical_alert&quot;:&quot;text&quot;,&quot;address_1&quot;:&quot;text&quot;,&quot;address_2&quot;:&quot;text&quot;,&quot;postal-code&quot;:&quot;text&quot;,&quot;&quot;:&quot;select&quot;,&quot;postal_code&quot;:&quot;text&quot;,&quot;phone_number&quot;:&quot;text&quot;,&quot;x-rays_enclosed&quot;:&quot;radio&quot;,&quot;Exo if RCT unrestorable?:&quot;:&quot;radio&quot;,&quot;RCT Final Filling by Dr. Campbell?: \\u25cb&quot;:&quot;radio&quot;,&quot;relevant_information&quot;:&quot;textarea&quot;,&quot;periodontal_therapy:&quot;:&quot;radio&quot;,&quot;referring_doctor&quot;:&quot;text&quot;,&quot;remarks&quot;:&quot;textarea&quot;,&quot;Please send us a referral pad&quot;:&quot;radio&quot;,&quot;Insured&quot;:&quot;text&quot;,&quot;carrier&quot;:&quot;text&quot;,&quot;employer&quot;:&quot;text&quot;,&quot;grouppolicy&quot;:&quot;text&quot;,&quot;id_sin&quot;:&quot;text&quot;,&quot;Division&quot;:&quot;text&quot;,&quot;Department&quot;:&quot;text&quot;,&quot;submit_1&quot;:&quot;submit&quot;},&quot;nonce_method&quot;:&quot;ajax&quot;}\"><form action=\"https:\/\/endoperiogroup.com\/refer-a-patient\/\" method=\"post\" class=\"fusion-form fusion-form-1089\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above\" style=\"\" data-form-id=\"1089\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">I am a doctor referring a patient <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-i_am_a_doctor_referring_a_patient-1-0\" type=\"radio\" value=\"Yes\" name=\"i_am_a_doctor_referring_a_patient\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-i_am_a_doctor_referring_a_patient-1-0\">Yes<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-i_am_a_doctor_referring_a_patient-1-1\" type=\"radio\" value=\"No\" name=\"i_am_a_doctor_referring_a_patient\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"radio-i_am_a_doctor_referring_a_patient-1-1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:20px;--awb-padding-right:35px;--awb-padding-bottom:20px;--awb-padding-left:35px;--awb-margin-top:25px;--awb-margin-bottom:25px;--awb-background-color:#f4f4f4;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-end fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-2\"><h3>Patient Contact Info<\/h3>\n<\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"First name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Last name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input autocomplete=\"no\" type=\"date\" data-first-day=\"1\"  data-format=\"\" tabindex=\"\" id=\"dob\" name=\"dob\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Date of birth*\"autocomplete=\"no\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"medical_alert\" id=\"medical_alert\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Medical Alert*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"address_1\" id=\"address_1\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"address_2\" id=\"address_2\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Address line 2\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"postal-code\" id=\"postal-code\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"City*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-select-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><div class=\"fusion-select-wrapper\"><select tabindex=\"\" id=\"\" name=\"\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"><option value=\"\" disabled selected>Province<\/option><option value=\"British Columbia\" >British Columbia<\/option><option value=\"Alberta\" >Alberta<\/option><option value=\"Manitoba\" >Manitoba<\/option><option value=\"Saskatchewan\" >Saskatchewan<\/option><option value=\"Ontario\" >Ontario<\/option><option value=\"Quebec\" >Quebec<\/option><option value=\"New Brunswick\" >New Brunswick<\/option><option value=\"Nova Scotia\" >Nova Scotia<\/option><option value=\"Prince Edward Island\" >Prince Edward Island<\/option><option value=\"Newfoundland\" >Newfoundland<\/option><\/select><div class=\"select-arrow\"><svg width=\"12\" height=\"8\" viewBox=\"0 0 12 8\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"> <path d=\"M1.5 1.75L6 6.25L10.5 1.75\" stroke=\"#6D6D6D\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"\/> <\/svg><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-color:rgba(86,86,86,0);--awb-bg-color-hover:rgba(86,86,86,0);--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"postal_code\" id=\"postal_code\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Postal code*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_3 1_3 fusion-flex-column\" style=\"--awb-bg-color:rgba(86,86,86,0);--awb-bg-color-hover:rgba(86,86,86,0);--awb-bg-size:cover;--awb-width-large:33.333333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:5.76%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:5.76%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"phone_number\" id=\"phone_number\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Phone Number*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-3 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:20px;--awb-padding-right:35px;--awb-padding-bottom:20px;--awb-padding-left:35px;--awb-margin-top:25px;--awb-margin-bottom:25px;--awb-background-color:#f4f4f4;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-stretch fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-color:rgba(86,86,86,0);--awb-bg-color-hover:rgba(86,86,86,0);--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-3\"><h3>Specializing in Endodontic Therapy<\/h3>\n<\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">X-rays enclosed<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-x-rays_enclosed-2-0\" type=\"radio\" value=\"Yes\" name=\"x-rays_enclosed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-x-rays_enclosed-2-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-x-rays_enclosed-2-1\" type=\"radio\" value=\"No\" name=\"x-rays_enclosed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-x-rays_enclosed-2-1\">No<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-x-rays_enclosed-2-2\" type=\"radio\" value=\"Emailed\" name=\"x-rays_enclosed\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-x-rays_enclosed-2-2\">Emailed<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Exo if RCT unrestorable?:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-exo-if-rct-unrestorable?:-3-0\" type=\"radio\" value=\"Yes\" name=\"Exo if RCT unrestorable?:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-exo-if-rct-unrestorable?:-3-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-exo-if-rct-unrestorable?:-3-1\" type=\"radio\" value=\"No\" name=\"Exo if RCT unrestorable?:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-exo-if-rct-unrestorable?:-3-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">RCT Final Filling by Dr. Campbell?:<\/span><\/div><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-rct-final-filling-by-dr.-campbell?:-\u25cb-4-0\" type=\"radio\" value=\"Yes\" name=\"RCT Final Filling by Dr. Campbell?: \u25cb\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-rct-final-filling-by-dr.-campbell?:-\u25cb-4-0\">Yes<\/label><\/div><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-rct-final-filling-by-dr.-campbell?:-\u25cb-4-1\" type=\"radio\" value=\"No\" name=\"RCT Final Filling by Dr. Campbell?: \u25cb\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-rct-final-filling-by-dr.-campbell?:-\u25cb-4-1\">No<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><label for=\"relevant_information\">Relevant Information<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"relevant_information\" name=\"relevant_information\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-color:rgba(86,86,86,0);--awb-bg-color-hover:rgba(86,86,86,0);--awb-bg-size:cover;--awb-border-color:#d6d6d6;--awb-border-style:solid;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-4\"><h3>Specialized Periodontal Therapy &amp; Aesthetic Implant Dentistry<\/h3>\n<\/div><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">Periodontal Therapy:<\/span><\/div><fieldset><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-periodontal_therapy:-5-0\" type=\"radio\" value=\"Periodontal Treatment\" name=\"periodontal_therapy:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-periodontal_therapy:-5-0\">Periodontal Treatment<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-periodontal_therapy:-5-1\" type=\"radio\" value=\"Implant Treatment\" name=\"periodontal_therapy:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-periodontal_therapy:-5-1\">Implant Treatment<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-periodontal_therapy:-5-2\" type=\"radio\" value=\"Gingival Grafting\" name=\"periodontal_therapy:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-periodontal_therapy:-5-2\">Gingival Grafting<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-periodontal_therapy:-5-3\" type=\"radio\" value=\"Crown Lengthening\" name=\"periodontal_therapy:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-periodontal_therapy:-5-3\">Crown Lengthening<\/label><\/div><div class=\"fusion-form-radio\"><input tabindex=\"\" id=\"radio-periodontal_therapy:-5-4\" type=\"radio\" value=\"Other\" name=\"periodontal_therapy:\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-periodontal_therapy:-5-4\">Other<\/label><\/div><\/fieldset><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><div class=\"fusion-form-label-wrapper\"><label for=\"referring_doctor\">Referring Doctor<\/label><\/div><input type=\"text\" name=\"referring_doctor\" id=\"referring_doctor\" value=\"\"  class=\"fusion-form-input\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-textarea-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><label for=\"remarks\">Remarks<\/label><textarea cols=\"40\"  minlength=\"0\"  rows=\"4\" tabindex=\"\" id=\"remarks\" name=\"remarks\" class=\"fusion-form-input\" data-holds-private-data=\"false\"><\/textarea><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-4 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-radio-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><fieldset><div class=\"fusion-form-radio option-inline\"><input tabindex=\"\" id=\"radio-please-send-us-a-referral-pad-6-0\" type=\"radio\" value=\"Please send us a referral pad\" name=\"Please send us a referral pad\" class=\"fusion-form-input\" data-holds-private-data=\"false\"\/><label for=\"radio-please-send-us-a-referral-pad-6-0\">Please send us a referral pad<\/label><\/div><\/fieldset><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-5 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:20px;--awb-padding-right:35px;--awb-padding-bottom:20px;--awb-padding-left:35px;--awb-margin-top:25px;--awb-margin-bottom:25px;--awb-background-color:#f4f4f4;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-stretch fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-17 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-color:rgba(86,86,86,0);--awb-bg-color-hover:rgba(86,86,86,0);--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-5\"><h3>Primary Dental Insurance<\/h3>\n<\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"Insured\" id=\"Insured\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insured\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"carrier\" id=\"carrier\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Carrier\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"employer\" id=\"employer\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Employer\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"grouppolicy\" id=\"grouppolicy\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Group\/Policy #\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"id_sin\" id=\"id_sin\" value=\"\"  class=\"fusion-form-input\" placeholder=\"ID or SIN\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"Division\" id=\"Division\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Division\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"Department\" id=\"Department\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Department #\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"dob\" id=\"dob\" value=\"\"  class=\"fusion-form-input\" placeholder=\"DOB\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-18 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-color:rgba(86,86,86,0);--awb-bg-color-hover:rgba(86,86,86,0);--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-6\"><h3>Secondary Dental Insurance<\/h3>\n<\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"Insured\" id=\"Insured\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Insured\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"carrier\" id=\"carrier\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Carrier\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"employer\" id=\"employer\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Employer\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"grouppolicy\" id=\"grouppolicy\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Group\/Policy #\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"id_sin\" id=\"id_sin\" value=\"\"  class=\"fusion-form-input\" placeholder=\"ID or SIN\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"Division\" id=\"Division\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Division\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"Department\" id=\"Department\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Department #\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above fusion-form-field-hidden\" style=\"\" data-form-id=\"1089\"><input type=\"text\" name=\"dob\" id=\"dob\" value=\"\"  class=\"fusion-form-input\" placeholder=\"DOB\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-6 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-19 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:30px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-form-field fusion-form-submit-field fusion-form-label-above\" style=\"\" data-form-id=\"1089\"><div style=\"text-align:center;\"><button type=\"submit\" class=\"fusion-button button-flat fusion-button-default-size button-default fusion-button-default button-2 fusion-button-span-no  form-form-submit button-default\" data-form-number=\"1089\" tabindex=\"\"><span class=\"fusion-button-text\">Submit Form<\/span><\/button><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/endoperiogroup.com\/wp-json\/wp\/v2\/pages\/13"}],"collection":[{"href":"https:\/\/endoperiogroup.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/endoperiogroup.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/endoperiogroup.com\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/endoperiogroup.com\/wp-json\/wp\/v2\/comments?post=13"}],"version-history":[{"count":0,"href":"https:\/\/endoperiogroup.com\/wp-json\/wp\/v2\/pages\/13\/revisions"}],"wp:attachment":[{"href":"https:\/\/endoperiogroup.com\/wp-json\/wp\/v2\/media?parent=13"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}