{"id":1536,"date":"2024-11-07T17:50:29","date_gmt":"2024-11-07T17:50:29","guid":{"rendered":"https:\/\/endostlaurent.com\/?page_id=1536\/"},"modified":"2024-11-20T16:45:44","modified_gmt":"2024-11-20T16:45:44","slug":"referring-doctors","status":"publish","type":"page","link":"https:\/\/endostlaurent.com\/en\/referring-doctors\/","title":{"rendered":"Referring doctors"},"content":{"rendered":"<style id=\"wpforms-css-vars-root\">\n\t\t\t\t:root {\n\t\t\t\t\t--wpforms-field-border-radius: 3px;\n--wpforms-field-border-style: solid;\n--wpforms-field-border-size: 1px;\n--wpforms-field-background-color: #ffffff;\n--wpforms-field-border-color: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-border-color-spare: rgba( 0, 0, 0, 0.25 );\n--wpforms-field-text-color: rgba( 0, 0, 0, 0.7 );\n--wpforms-field-menu-color: #ffffff;\n--wpforms-label-color: rgba( 0, 0, 0, 0.85 );\n--wpforms-label-sublabel-color: rgba( 0, 0, 0, 0.55 );\n--wpforms-label-error-color: #d63637;\n--wpforms-button-border-radius: 3px;\n--wpforms-button-border-style: none;\n--wpforms-button-border-size: 1px;\n--wpforms-button-background-color: #066aab;\n--wpforms-button-border-color: #066aab;\n--wpforms-button-text-color: #ffffff;\n--wpforms-page-break-color: #066aab;\n--wpforms-background-image: none;\n--wpforms-background-position: center center;\n--wpforms-background-repeat: no-repeat;\n--wpforms-background-size: cover;\n--wpforms-background-width: 100px;\n--wpforms-background-height: 100px;\n--wpforms-background-color: rgba( 0, 0, 0, 0 );\n--wpforms-background-url: none;\n--wpforms-container-padding: 0px;\n--wpforms-container-border-style: none;\n--wpforms-container-border-width: 1px;\n--wpforms-container-border-color: #000000;\n--wpforms-container-border-radius: 3px;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-css-vars-1531-block-3aa59be8-009e-4b33-a830-8970bc88e410\">\n\t\t\t\t#wpforms-1531.wpforms-block-3aa59be8-009e-4b33-a830-8970bc88e410 {\n\t\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\n\t\t\t\t}\n\t\t\t<\/style><style id=\"wpforms-custom-css-1531-block-3aa59be8-009e-4b33-a830-8970bc88e410\">\n\t\t\t\t.title {\ndisplay: none !important;\n}\n.teeth-bottom {\npadding-top: 0px !important;\n}\n\n.teeth-bottom {\n  ul {\n  border-top: 2px solid black !important;\n  padding-top: 15px !important;\n.choice-4 {\nborder-right: 2px solid black !important;\n  padding-top: 15px !important;\n  margin-top: -15px !important;\n  padding-bottom: 15px !important;\n  margin-bottom: -15px !important;\n  padding-right: 15px !important;\n}\n  }\n}\n.teeth-top{\n\n.choice-8 {\nborder-right: 2px solid black !important;\n  padding-top: 10px !important;\n  margin-top: -10px !important;\n  padding-bottom: 20px !important;\n  margin-bottom: -20px !important;\n  padding-right: 15px !important;\n}\n}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-3aa59be8-009e-4b33-a830-8970bc88e410 wpforms-render-modern\" id=\"wpforms-1531\"><form id=\"wpforms-form-1531\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"1531\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/1536?wpforms_form_id=1531\" data-token=\"1176d992bc7b93e0296943ebee81bd68\" data-token-time=\"1776938810\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-1531-field_42-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_42\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1531-field_42\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][42][date]\" placeholder=\"(DD\/MM\/YYYY)\" aria-errormessage=\"wpforms-1531-field_42-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1531-field_1-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"1\"><h3 id=\"wpforms-1531-field_1\" aria-errormessage=\"wpforms-1531-field_1-error\">Referring dentist<\/h3><\/div><div id=\"wpforms-1531-field_27-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"27\"><fieldset><legend class=\"wpforms-field-label\">Dr. <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1531-field_27\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][27][first]\" aria-errormessage=\"wpforms-1531-field_27-error\" required><label for=\"wpforms-1531-field_27\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1531-field_27-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][27][last]\" aria-errormessage=\"wpforms-1531-field_27-last-error\" required><label for=\"wpforms-1531-field_27-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1531-field_38-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"38\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_38\">Phone 1 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1531-field_38\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][38]\" placeholder=\"(---) --- - ----\" aria-label=\"Phone 1\" aria-errormessage=\"wpforms-1531-field_38-error\" required><\/div><div id=\"wpforms-1531-field_39-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_39\">Phone 2<\/label><input type=\"tel\" id=\"wpforms-1531-field_39\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][39]\" placeholder=\"(---) --- - ----\" aria-label=\"Phone 2\" aria-errormessage=\"wpforms-1531-field_39-error\" ><\/div><div id=\"wpforms-1531-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_6\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-1531-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" placeholder=\"Email\" spellcheck=\"false\" aria-errormessage=\"wpforms-1531-field_6-error\" required><\/div><div id=\"wpforms-1531-field_8-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"8\"><h3 id=\"wpforms-1531-field_8\" aria-errormessage=\"wpforms-1531-field_8-error\">Patient<\/h3><\/div><div id=\"wpforms-1531-field_9-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Multiple Choice<\/legend><ul id=\"wpforms-1531-field_9\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-1531-field_9_1\" name=\"wpforms[fields][9]\" value=\"Mr.\" aria-errormessage=\"wpforms-1531-field_9_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_9_1\">Mr.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-1531-field_9_2\" name=\"wpforms[fields][9]\" value=\"Ms.\" aria-errormessage=\"wpforms-1531-field_9_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_9_2\">Ms.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1531-field_23-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"23\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-1531-field_23\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][23][first]\" aria-errormessage=\"wpforms-1531-field_23-error\" required><label for=\"wpforms-1531-field_23\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-1531-field_23-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][23][last]\" aria-errormessage=\"wpforms-1531-field_23-last-error\" required><label for=\"wpforms-1531-field_23-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-1531-field_40-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_40\">Phone 1 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-1531-field_40\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][40]\" placeholder=\"(---) --- - ----\" aria-label=\"Phone 1\" aria-errormessage=\"wpforms-1531-field_40-error\" required><\/div><div id=\"wpforms-1531-field_41-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_41\">Phone 2<\/label><input type=\"tel\" id=\"wpforms-1531-field_41\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][41]\" placeholder=\"(---) --- - ----\" aria-label=\"Phone 2\" aria-errormessage=\"wpforms-1531-field_41-error\" ><\/div><div id=\"wpforms-1531-field_14-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_14\">Email<\/label><input type=\"email\" id=\"wpforms-1531-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" placeholder=\"Email\" spellcheck=\"false\" aria-errormessage=\"wpforms-1531-field_14-error\" ><\/div><div id=\"wpforms-1531-field_43-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_43\">Date of birth <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-1531-field_43\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-small\" data-date-format=\"d\/m\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][43][date]\" placeholder=\"(DD\/MM\/YYYY)\" aria-errormessage=\"wpforms-1531-field_43-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-1531-field_44-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"44\"><fieldset><legend class=\"wpforms-field-label\">Canadian Dental Care Plan <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-1531-field_44\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_44_1\" name=\"wpforms[fields][44][]\" value=\"Yes\" aria-errormessage=\"wpforms-1531-field_44_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_44_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_44_2\" name=\"wpforms[fields][44][]\" value=\"No\" aria-errormessage=\"wpforms-1531-field_44_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_44_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1531-field_16-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"16\"><h3 id=\"wpforms-1531-field_16\" aria-errormessage=\"wpforms-1531-field_16-error\">Tooth (Teeth)<\/h3><\/div><div id=\"wpforms-1531-field_30-container\" class=\"wpforms-field wpforms-field-checkbox teeth-top wpforms-list-inline\" data-field-id=\"30\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Teeth Top<\/legend><ul id=\"wpforms-1531-field_30\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_1\" name=\"wpforms[fields][30][]\" value=\"18\" aria-errormessage=\"wpforms-1531-field_30_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_1\">18<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_2\" name=\"wpforms[fields][30][]\" value=\"17\" aria-errormessage=\"wpforms-1531-field_30_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_2\">17<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_3\" name=\"wpforms[fields][30][]\" value=\"16\" aria-errormessage=\"wpforms-1531-field_30_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_3\">16<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_4\" name=\"wpforms[fields][30][]\" value=\"15\" aria-errormessage=\"wpforms-1531-field_30_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_4\">15<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_5\" name=\"wpforms[fields][30][]\" value=\"14\" aria-errormessage=\"wpforms-1531-field_30_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_5\">14<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_6\" name=\"wpforms[fields][30][]\" value=\"13\" aria-errormessage=\"wpforms-1531-field_30_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_6\">13<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_7\" name=\"wpforms[fields][30][]\" value=\"12\" aria-errormessage=\"wpforms-1531-field_30_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_7\">12<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_8\" name=\"wpforms[fields][30][]\" value=\"11\" aria-errormessage=\"wpforms-1531-field_30_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_8\">11<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_14\" name=\"wpforms[fields][30][]\" value=\"21\" aria-errormessage=\"wpforms-1531-field_30_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_14\">21<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_13\" name=\"wpforms[fields][30][]\" value=\"22\" aria-errormessage=\"wpforms-1531-field_30_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_13\">22<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_12\" name=\"wpforms[fields][30][]\" value=\"23\" aria-errormessage=\"wpforms-1531-field_30_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_12\">23<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_11\" name=\"wpforms[fields][30][]\" value=\"24\" aria-errormessage=\"wpforms-1531-field_30_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_11\">24<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_10\" name=\"wpforms[fields][30][]\" value=\"25\" aria-errormessage=\"wpforms-1531-field_30_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_10\">25<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_9\" name=\"wpforms[fields][30][]\" value=\"26\" aria-errormessage=\"wpforms-1531-field_30_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_9\">26<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_16\" name=\"wpforms[fields][30][]\" value=\"27\" aria-errormessage=\"wpforms-1531-field_30_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_16\">27<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_30_15\" name=\"wpforms[fields][30][]\" value=\"28\" aria-errormessage=\"wpforms-1531-field_30_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_30_15\">28<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1531-field_31-container\" class=\"wpforms-field wpforms-field-checkbox teeth-bottom wpforms-list-inline\" data-field-id=\"31\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Teeth Bottom<\/legend><ul id=\"wpforms-1531-field_31\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_1\" name=\"wpforms[fields][31][]\" value=\"48\" aria-errormessage=\"wpforms-1531-field_31_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_1\">48<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_2\" name=\"wpforms[fields][31][]\" value=\"47\" aria-errormessage=\"wpforms-1531-field_31_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_2\">47<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_3\" name=\"wpforms[fields][31][]\" value=\"46\" aria-errormessage=\"wpforms-1531-field_31_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_3\">46<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_8\" name=\"wpforms[fields][31][]\" value=\"45\" aria-errormessage=\"wpforms-1531-field_31_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_8\">45<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_7\" name=\"wpforms[fields][31][]\" value=\"44\" aria-errormessage=\"wpforms-1531-field_31_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_7\">44<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_6\" name=\"wpforms[fields][31][]\" value=\"43\" aria-errormessage=\"wpforms-1531-field_31_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_6\">43<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_5\" name=\"wpforms[fields][31][]\" value=\"42\" aria-errormessage=\"wpforms-1531-field_31_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_5\">42<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_4\" name=\"wpforms[fields][31][]\" value=\"41\" aria-errormessage=\"wpforms-1531-field_31_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_4\">41<\/label><\/li><li class=\"choice-16 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_16\" name=\"wpforms[fields][31][]\" value=\"31\" aria-errormessage=\"wpforms-1531-field_31_16-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_16\">31<\/label><\/li><li class=\"choice-15 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_15\" name=\"wpforms[fields][31][]\" value=\"32\" aria-errormessage=\"wpforms-1531-field_31_15-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_15\">32<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_14\" name=\"wpforms[fields][31][]\" value=\"33\" aria-errormessage=\"wpforms-1531-field_31_14-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_14\">33<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_13\" name=\"wpforms[fields][31][]\" value=\"34\" aria-errormessage=\"wpforms-1531-field_31_13-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_13\">34<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_12\" name=\"wpforms[fields][31][]\" value=\"35\" aria-errormessage=\"wpforms-1531-field_31_12-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_12\">35<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_11\" name=\"wpforms[fields][31][]\" value=\"36\" aria-errormessage=\"wpforms-1531-field_31_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_11\">36<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_10\" name=\"wpforms[fields][31][]\" value=\"37\" aria-errormessage=\"wpforms-1531-field_31_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_10\">37<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_31_9\" name=\"wpforms[fields][31][]\" value=\"38\" aria-errormessage=\"wpforms-1531-field_31_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_31_9\">38<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1531-field_29-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"29\"><fieldset><legend class=\"wpforms-field-label\">Treatment<\/legend><ul id=\"wpforms-1531-field_29\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_1\" name=\"wpforms[fields][29][]\" value=\"Emengency treatment\" aria-errormessage=\"wpforms-1531-field_29_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_1\">Emengency treatment<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_2\" name=\"wpforms[fields][29][]\" value=\"3D Scan\" aria-errormessage=\"wpforms-1531-field_29_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_2\">3D Scan<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_3\" name=\"wpforms[fields][29][]\" value=\"Diagnosis\" aria-errormessage=\"wpforms-1531-field_29_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_3\">Diagnosis<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_4\" name=\"wpforms[fields][29][]\" value=\"Root canal treatment\" aria-errormessage=\"wpforms-1531-field_29_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_4\">Root canal treatment<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_5\" name=\"wpforms[fields][29][]\" value=\"Retreatment\" aria-errormessage=\"wpforms-1531-field_29_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_5\">Retreatment<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_6\" name=\"wpforms[fields][29][]\" value=\"Apical surgery\" aria-errormessage=\"wpforms-1531-field_29_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_6\">Apical surgery<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_7\" name=\"wpforms[fields][29][]\" value=\"Apexification or regeneration\" aria-errormessage=\"wpforms-1531-field_29_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_7\">Apexification or regeneration<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_9\" name=\"wpforms[fields][29][]\" value=\"Intentional replantation\" aria-errormessage=\"wpforms-1531-field_29_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_9\">Intentional replantation<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_8\" name=\"wpforms[fields][29][]\" value=\"Internal bleaching\" aria-errormessage=\"wpforms-1531-field_29_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_8\">Internal bleaching<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_11\" name=\"wpforms[fields][29][]\" value=\"Trauma management\" aria-errormessage=\"wpforms-1531-field_29_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_11\">Trauma management<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_29_10\" name=\"wpforms[fields][29][]\" value=\"Internal or External Resorption\" aria-errormessage=\"wpforms-1531-field_29_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_29_10\">Internal or External Resorption<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1531-field_33-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"33\"><fieldset><legend class=\"wpforms-field-label\">Restore with<\/legend><ul id=\"wpforms-1531-field_33\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_33_1\" name=\"wpforms[fields][33][]\" value=\"Cotton pellet &amp; temporary restoration\" aria-errormessage=\"wpforms-1531-field_33_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_33_1\">Cotton pellet &amp; temporary restoration<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_33_2\" name=\"wpforms[fields][33][]\" value=\"Final composite\" aria-errormessage=\"wpforms-1531-field_33_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_33_2\">Final composite<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1531-field_32-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\">Post Space<\/legend><ul id=\"wpforms-1531-field_32\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_32_1\" name=\"wpforms[fields][32][]\" value=\"Yes\" aria-errormessage=\"wpforms-1531-field_32_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_32_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-1531-field_32_2\" name=\"wpforms[fields][32][]\" value=\"No\" aria-errormessage=\"wpforms-1531-field_32_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-1531-field_32_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-1531-field_19-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"19\"><h3 id=\"wpforms-1531-field_19\" aria-errormessage=\"wpforms-1531-field_19-error\">Files<\/h3><\/div><div id=\"wpforms-1531-field_20-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_20\">Attach your Xrays (.pdf .jpg)<\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"20\"\n\t\tdata-form-id=\"1531\"\n\t\tdata-input-name=\"wpforms_1531_20\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,xls\"\n\t\tdata-max-size=\"2097152\"\n\t\tdata-max-file-number=\"15\"\n\t\tdata-post-max-size=\"2097152\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" 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