{"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-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--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\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=\"b75551475c965a618b6904747305888c\" data-token-time=\"1780764265\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">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 role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" 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 role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" 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>\t\t<div id=\"wpforms-1531-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-1531-field_2\" >birth Bottom Phone<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-1531-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<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 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height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 15 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-1531-field_20\"\n\t\tname=\"wpforms_1531_20\" \t\tvalue=\"\">\n<div id=\"wpforms-1531-field_20-description\" class=\"wpforms-field-description\">No special characters in file name please.<\/div><\/div><div id=\"wpforms-1531-field_21-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-1531-field_21\">Comments<\/label><textarea id=\"wpforms-1531-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-1531-field_21-error\" ><\/textarea><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = 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-->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"class_list":["post-1536","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/pages\/1536","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/comments?post=1536"}],"version-history":[{"count":13,"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/pages\/1536\/revisions"}],"predecessor-version":[{"id":1568,"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/pages\/1536\/revisions\/1568"}],"wp:attachment":[{"href":"https:\/\/endostlaurent.com\/en\/wp-json\/wp\/v2\/media?parent=1536"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}