{"id":54,"date":"2022-07-06T13:33:37","date_gmt":"2022-07-06T12:33:37","guid":{"rendered":"http:\/\/susseximplantcentre.somnowellmarketing.com\/?page_id=54"},"modified":"2022-07-27T08:45:22","modified_gmt":"2022-07-27T07:45:22","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/www.susseximplantcentre.com\/staging\/2525\/referral-form\/","title":{"rendered":"Referral"},"content":{"rendered":"<section id=\"referral-form\" class=\"content-section bg-gray py-2 py-md-3\" >\n<div class=\"container\">\n    <div class=\"row gx-lg-2\">\n        \n<div class=\"col-12\">\n    \n<div class=\"wpcf7 no-js\" id=\"wpcf7-f542-o1\" lang=\"en-GB\" dir=\"ltr\" data-wpcf7-id=\"542\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/staging\/2525\/wp-json\/wp\/v2\/pages\/54#wpcf7-f542-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"542\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_GB\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f542-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"text-center\">\n    <h2 class=\"text-white\">Referral Form<\/h2>\n    <p>Please fill out the information form.<\/p>\n<\/div>\n<div><label class=\"form-label\">Referring Practitioner *<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"practitioner-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"practitioner-name\" \/><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"referring-practice\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Referring Practice\" value=\"\" type=\"text\" name=\"referring-practice\" \/><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"practice-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Practice Address\" value=\"\" type=\"text\" name=\"practice-address\" \/><\/span><\/div>\n<div class=\"row\">\n    <div class=\"col-sm-6\"><span class=\"wpcf7-form-control-wrap\" data-name=\"practitioner-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"practitioner-phone\" \/><\/span><\/div>\n    <div class=\"col-sm-6\"><span class=\"wpcf7-form-control-wrap\" data-name=\"practitioner-fax\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fax\" value=\"\" type=\"text\" name=\"practitioner-fax\" \/><\/span><\/div>\n<\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"practitioner-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"practitioner-email\" \/><\/span><\/div>\n<div><label class=\"form-label\">Patient Details *<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" value=\"\" type=\"text\" name=\"patient-name\" \/><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-date-birth\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date Of Birth\" value=\"\" type=\"text\" name=\"patient-date-birth\" \/><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Practice Address\" value=\"\" type=\"text\" name=\"patient-address\" \/><\/span><\/div>\n<div class=\"row\">\n    <div class=\"col-sm-6\"><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone\" value=\"\" type=\"text\" name=\"patient-phone\" \/><\/span><\/div>\n    <div class=\"col-sm-6\"><span class=\"wpcf7-form-control-wrap\" data-name=\"patient-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"patient-email\" \/><\/span><\/div>\n<\/div>\n<div><label class=\"form-label\">Referral Details *<\/label><\/div>\n<div><label class=\"form-label ps-1\">Implantology<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-implantology\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-implantology[]\" value=\"Consultation\" \/><span class=\"wpcf7-list-item-label\">Consultation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-implantology[]\" value=\"Placement Only\" \/><span class=\"wpcf7-list-item-label\">Placement Only<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-implantology[]\" value=\"Placement &amp; Restoration\" \/><span class=\"wpcf7-list-item-label\">Placement &amp; Restoration<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-implantology[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"implantology-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Other\" value=\"\" type=\"text\" name=\"implantology-other\" \/><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"implantology-tooth-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Tooth Number(s)\" value=\"\" type=\"text\" name=\"implantology-tooth-number\" \/><\/span><\/div>\n<div><label class=\"form-label ps-1\">Endodontics<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-endodontics\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-endodontics[]\" value=\"Incisor\/Premolar\" \/><span class=\"wpcf7-list-item-label\">Incisor\/Premolar<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-endodontics[]\" value=\"Molar\" \/><span class=\"wpcf7-list-item-label\">Molar<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-endodontics[]\" value=\"Re-RCT\" \/><span class=\"wpcf7-list-item-label\">Re-RCT<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-endodontics[]\" value=\"Root-End Surgery\" \/><span class=\"wpcf7-list-item-label\">Root-End Surgery<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-endodontics[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"endodontics-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Other\" value=\"\" type=\"text\" name=\"endodontics-other\" \/><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"endodontics-tooth-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Tooth Number(s)\" value=\"\" type=\"text\" name=\"endodontics-tooth-number\" \/><\/span><\/div>\n<div><label class=\"form-label ps-1\">Oral Surgery<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-Surgery\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-Surgery[]\" value=\"Consultation\" \/><span class=\"wpcf7-list-item-label\">Consultation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-Surgery[]\" value=\"Tooth Removal \/ Root Removal\" \/><span class=\"wpcf7-list-item-label\">Tooth Removal \/ Root Removal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-Surgery[]\" value=\"Surgical Tooth Removal\" \/><span class=\"wpcf7-list-item-label\">Surgical Tooth Removal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"checkbox-Surgery[]\" value=\"Socket Preservation\" \/><span class=\"wpcf7-list-item-label\">Socket Preservation<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-Surgery[]\" value=\"Wisdom Tooth Removal\" \/><span class=\"wpcf7-list-item-label\">Wisdom Tooth Removal<\/span><\/label><\/span><\/span><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"surgery-tooth-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Tooth Number(s)\" value=\"\" type=\"text\" name=\"surgery-tooth-number\" \/><\/span><\/div>\n<div><label class=\"form-label ps-1\">CBCT Scan<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-cbct\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-cbct[]\" value=\"With Report\" \/><span class=\"wpcf7-list-item-label\">With Report<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-cbct[]\" value=\"Without Report\" \/><span class=\"wpcf7-list-item-label\">Without Report<\/span><\/label><\/span><\/span><\/span><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"cbct-area\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Area\" value=\"\" type=\"text\" name=\"cbct-area\" \/><\/span><\/div>\n<div><label class=\"form-label ps-1\">OPG<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-OPG\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-OPG[]\" value=\"With Report\" \/><span class=\"wpcf7-list-item-label\">With Report<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-OPG[]\" value=\"Without Report\" \/><span class=\"wpcf7-list-item-label\">Without Report<\/span><\/label><\/span><\/span><\/span><\/div>\n<div><label class=\"form-label ps-1\">Patient would like to have IV sedation<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-sedation\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"checkbox-sedation[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"checkbox-sedation[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span><\/div>\n<div><label class=\"form-label ps-1\">Brief description of case<\/label><\/div>\n<div><span class=\"wpcf7-form-control-wrap\" data-name=\"brief-description\"><textarea cols=\"40\" rows=\"4\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea form-control\" aria-invalid=\"false\" placeholder=\"(in case of CBCT please provide IRMER justification)\" name=\"brief-description\"><\/textarea><\/span><\/div>\n<div><label class=\"form-label ps-1\">Practitioner's Signature<\/label><\/div>\n<div class=\"mb-1\"><span class=\"wpcf7-form-control-wrap\" data-name=\"electronic-signature\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"This will act as the practitioner\u2019s electronic signature.\" value=\"\" type=\"text\" name=\"electronic-signature\" \/><\/span><\/div>\n<div class=\"mb-1\"><span class=\"wpcf7-form-control-wrap\" data-name=\"your-consent\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-consent\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">You have read and agree to our <a href=\"https:\/\/www.susseximplantcentre.com\/staging\/2525\/privacy-notice\/\" target=\"_blank\">Privacy Policy<\/a>.<\/span><\/label><\/span><\/span><\/span><\/div>\n<div class=\"mt-1 row justify-content-center\">\n<p style=\"color: #e9bd5a; margin: 40px 0 10px 0; font-size: 0.66667rem;\">To combat spam and bots, please answer the simple question below.<\/p>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"quiz-688\"><label><span class=\"wpcf7-quiz-label\">1 + 1 =<\/span> <input size=\"40\" class=\"wpcf7-form-control wpcf7-quiz\" autocomplete=\"off\" aria-required=\"true\" aria-invalid=\"false\" type=\"text\" name=\"quiz-688\" \/><\/label><input type=\"hidden\" name=\"_wpcf7_quiz_answer_quiz-688\" value=\"b22f8c992c79120217bbb037657c2593\" \/><\/span>\n    <div class=\"col-md-6\"><input class=\"wpcf7-form-control wpcf7-submit has-spinner btn btn-lg btn-primary\" type=\"submit\" value=\"SUBMIT REFERRAL FORM\" \/><\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\n    <\/div>\n<\/div>\n<\/section>\n\n","protected":false},"excerpt":{"rendered":"<p>Referral Form Please fill out the information form. Referring Practitioner * Patient Details * Referral Details * Implantology ConsultationPlacement OnlyPlacement &amp; RestorationOther Endodontics Incisor\/PremolarMolarRe-RCTRoot-End SurgeryOther Oral Surgery ConsultationTooth Removal \/ Root RemovalSurgical Tooth RemovalSocket PreservationWisdom Tooth Removal CBCT Scan With ReportWithout Report OPG With ReportWithout Report Patient would like to have IV sedation YesNo Brief<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"nf_dc_page":"","footnotes":""},"class_list":["post-54","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Referral - Sussex Implant Centre<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.susseximplantcentre.com\/referral-form\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Referral - Sussex Implant Centre\" \/>\n<meta property=\"og:description\" content=\"Referral Form Please fill out the information form. 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