{"id":5768,"date":"2013-09-16T11:46:21","date_gmt":"2013-09-16T11:46:21","guid":{"rendered":"\/?page_id=5768"},"modified":"2016-08-02T23:49:16","modified_gmt":"2016-08-02T23:49:16","slug":"referral-form-2","status":"publish","type":"page","link":"http:\/\/precisesmile.com\/referral-form-2","title":{"rendered":"Patient Referral Form"},"content":{"rendered":"<p>If you would like to print the form for your records, or fill out the form and return it to our office later, you <a href=\"\/wp-content\/uploads\/2013\/09\/Schmitt-Referral-Form2.pdf\">can download the pdf<\/a>.<\/p>\n<div class='gf_browser_gecko gform_wrapper referalForm_wrapper' id='gform_wrapper_2' >\n<form method='post' enctype='multipart\/form-data'  id='gform_2' class='referalForm' action='\/wp-json\/wp\/v2\/pages\/5768'>\n<div class='gform_heading'>\n<h3 class='gform_title'>Referral<\/h3>\n<p>                            <span class='gform_description'><\/span>\n                        <\/div>\n<div class='gform_body'>\n<ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'>\n<li id='field_2_1' class='gfield gf_left_half field_sublabel_below field_description_below' ><label class='gfield_label gfield_label_before_complex' for='input_2_1_3' >Patient&#039;s Name<\/label>\n<div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_2_1'>\n                            <span id='input_2_1_3_container' class='name_first' ><br \/>\n                                                    <input type='text' name='input_1.3' id='input_2_1_3' value='' aria-label='First name' tabindex='1'   aria-invalid=\"false\" \/><br \/>\n                                                    <label for='input_2_1_3' >First<\/label><br \/>\n                                               <\/span><br \/>\n                            <span id='input_2_1_6_container' class='name_last' ><br \/>\n                                                    <input type='text' name='input_1.6' id='input_2_1_6' value='' aria-label='Last name' tabindex='2'   aria-invalid=\"false\" \/><br \/>\n                                                    <label for='input_2_1_6' >Last<\/label><br \/>\n                                                <\/span><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p><\/div>\n<\/li>\n<li id='field_2_2' class='gfield gf_right_half field_sublabel_below field_description_below' ><label class='gfield_label' for='input_2_2' >Today&#039;s Date<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_2' id='input_2_2' type='text' value='' class='datepicker medium mdy datepicker_with_icon' tabindex='3'  \/>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_2_2' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li>\n<li id='field_2_3' class='gfield gf_left_half field_sublabel_below field_description_below' ><label class='gfield_label' for='input_2_3' >Appointment Date<\/label>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_2_3' type='text' value='' class='datepicker medium mdy datepicker_with_icon' tabindex='4'  \/>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_2_3' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li>\n<li id='field_2_4' class='gfield gf_right_half field_sublabel_below field_description_below' ><label class='gfield_label gfield_label_before_complex' for='input_2_4_1' >Appointment Time<\/label>\n<div class='clear-multi'>\n<div class='gfield_time_hour ginput_container ginput_container_time' id='input_2_4'>\n                            <input type='text' maxlength='2' name='input_4[]' id='input_2_4_1' value='' tabindex='5'   \/> <i>:<\/i><br \/>\n                            <label for='input_2_4_1' >HH<\/label>\n                        <\/div>\n<div class='gfield_time_minute ginput_container ginput_container_time'>\n                            <input type='text' maxlength='2' name='input_4[]' id='input_2_4_2' value='' tabindex='6'   \/><br \/>\n                            <label for='input_2_4_2' >MM<\/label>\n                        <\/div>\n<div class='gfield_time_ampm ginput_container ginput_container_time' >\n                                                            <select name='input_4[]' id='input_2_4_3' tabindex='7' ><option value='am' >AM<\/option><option value='pm' >PM<\/option><\/select>\n                                                          <\/div>\n<\/p><\/div>\n<\/li>\n<li id='field_2_12' class='gfield gf_left_half field_sublabel_below field_description_below' ><label class='gfield_label' for='input_2_12' >Referring Doctor<\/label>\n<div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='medium'  tabindex='8'    aria-invalid=\"false\" \/><\/div>\n<\/li>\n<li id='field_2_6' class='gfield gf_left_half field_sublabel_below field_description_below' ><label class='gfield_label'  >Refer For:<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_2_6'>\n<li class='gchoice_2_6_1'>\n\t\t\t\t\t\t\t\t<input name='input_6.1' type='checkbox'  value='Second Opinion'  id='choice_2_6_1' tabindex='9'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_6_1' id='label_2_6_1'>Second Opinion<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_6_2'>\n\t\t\t\t\t\t\t\t<input name='input_6.2' type='checkbox'  value='Comprehensive Care'  id='choice_2_6_2' tabindex='10'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_6_2' id='label_2_6_2'>Comprehensive Care<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_6_3'>\n\t\t\t\t\t\t\t\t<input name='input_6.3' type='checkbox'  value='Limited Scope Care (in tx section)'  id='choice_2_6_3' tabindex='11'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_6_3' id='label_2_6_3'>Limited Scope Care (in tx section)<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_6_4'>\n\t\t\t\t\t\t\t\t<input name='input_6.4' type='checkbox'  value='Call Referral Prior to Biginning Treatment'  id='choice_2_6_4' tabindex='12'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_6_4' id='label_2_6_4'>Call Referral Prior to Biginning Treatment<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_6_5'>\n\t\t\t\t\t\t\t\t<input name='input_6.5' type='checkbox'  value='CBCT Only (disk copy given to patient)'  id='choice_2_6_5' tabindex='13'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_6_5' id='label_2_6_5'>CBCT Only (disk copy given to patient)<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_6_6'>\n\t\t\t\t\t\t\t\t<input name='input_6.6' type='checkbox'  value='other (Please Explain)'  id='choice_2_6_6' tabindex='14'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_6_6' id='label_2_6_6'>other (Please Explain)<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id='field_2_16' class='gfield field_sublabel_below field_description_below' ><label class='gfield_label' for='input_2_16' >Please Explain Referral Details<\/label>\n<div class='ginput_container'><textarea name='input_16' id='input_2_16' class='textarea medium' tabindex='15'    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/li>\n<li id='field_2_13' class='gfield gsection field_sublabel_below field_description_below' >\n<h2 class='gsection_title'>Prosthodontic Treatment<\/h2>\n<\/li>\n<li id='field_2_7' class='gfield gf_left_half field_sublabel_below field_description_below' ><label class='gfield_label'  >Fixed Prosthodontics<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_2_7'>\n<li class='gchoice_2_7_1'>\n\t\t\t\t\t\t\t\t<input name='input_7.1' type='checkbox'  value='Functional Rehabilitation'  id='choice_2_7_1' tabindex='16'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_1' id='label_2_7_1'>Functional Rehabilitation<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_7_2'>\n\t\t\t\t\t\t\t\t<input name='input_7.2' type='checkbox'  value='Esthetic Rejuvination'  id='choice_2_7_2' tabindex='17'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_2' id='label_2_7_2'>Esthetic Rejuvination<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_7_3'>\n\t\t\t\t\t\t\t\t<input name='input_7.3' type='checkbox'  value='Perio\/Pros Rehabilitation'  id='choice_2_7_3' tabindex='18'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_3' id='label_2_7_3'>Perio\/Pros Rehabilitation<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_7_4'>\n\t\t\t\t\t\t\t\t<input name='input_7.4' type='checkbox'  value='Failing Dentition'  id='choice_2_7_4' tabindex='19'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_4' id='label_2_7_4'>Failing Dentition<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_7_5'>\n\t\t\t\t\t\t\t\t<input name='input_7.5' type='checkbox'  value='other (please explain below)'  id='choice_2_7_5' tabindex='20'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_7_5' id='label_2_7_5'>other (please explain below)<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id='field_2_11' class='gfield gf_right_half field_sublabel_below field_description_below' ><label class='gfield_label'  >Implant Prosthodontics<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_2_11'>\n<li class='gchoice_2_11_1'>\n\t\t\t\t\t\t\t\t<input name='input_11.1' type='checkbox'  value='Single Tooth Replacement\u00a0'  id='choice_2_11_1' tabindex='21'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1'>Single Tooth Replacement\u00a0<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_11_2'>\n\t\t\t\t\t\t\t\t<input name='input_11.2' type='checkbox'  value='Multiple Tooth Replacement\u00a0'  id='choice_2_11_2' tabindex='22'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_11_2' id='label_2_11_2'>Multiple Tooth Replacement\u00a0<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_11_3'>\n\t\t\t\t\t\t\t\t<input name='input_11.3' type='checkbox'  value='Implant Supported Dentures\u00a0'  id='choice_2_11_3' tabindex='23'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_11_3' id='label_2_11_3'>Implant Supported Dentures\u00a0<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_11_4'>\n\t\t\t\t\t\t\t\t<input name='input_11.4' type='checkbox'  value='Tooth\/Soft Tissue Recon.'  id='choice_2_11_4' tabindex='24'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_11_4' id='label_2_11_4'>Tooth\/Soft Tissue Recon.<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_11_5'>\n\t\t\t\t\t\t\t\t<input name='input_11.5' type='checkbox'  value='Malpositioned Implant Recon.'  id='choice_2_11_5' tabindex='25'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_11_5' id='label_2_11_5'>Malpositioned Implant Recon.<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id='field_2_14' class='gfield field_sublabel_below field_description_below' ><label class='gfield_label' for='input_2_14' >Please Explain Prosthodontic Details<\/label>\n<div class='ginput_container'><textarea name='input_14' id='input_2_14' class='textarea medium' tabindex='26'    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/li>\n<li id='field_2_15' class='gfield gsection field_sublabel_below field_description_below' >\n<h2 class='gsection_title'>Other Information<\/h2>\n<\/li>\n<li id='field_2_8' class='gfield gf_left_half field_sublabel_below field_description_below' ><label class='gfield_label'  >Radiographs<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_2_8'>\n<li class='gchoice_2_8_1'>\n\t\t\t\t\t\t\t\t<input name='input_8.1' type='checkbox'  value='Take All Necessary'  id='choice_2_8_1' tabindex='27'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_1' id='label_2_8_1'>Take All Necessary<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_8_2'>\n\t\t\t\t\t\t\t\t<input name='input_8.2' type='checkbox'  value='Mailed \/E-mailed'  id='choice_2_8_2' tabindex='28'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_2' id='label_2_8_2'>Mailed \/E-mailed<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_8_3'>\n\t\t\t\t\t\t\t\t<input name='input_8.3' type='checkbox'  value='Patient Will Bring'  id='choice_2_8_3' tabindex='29'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_8_3' id='label_2_8_3'>Patient Will Bring<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id='field_2_9' class='gfield gf_right_half field_sublabel_below field_description_below' ><label class='gfield_label'  >Maintenance<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_2_9'>\n<li class='gchoice_2_9_1'>\n\t\t\t\t\t\t\t\t<input name='input_9.1' type='checkbox'  value='Return for Comp Care'  id='choice_2_9_1' tabindex='30'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_1' id='label_2_9_1'>Return for Comp Care<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_9_2'>\n\t\t\t\t\t\t\t\t<input name='input_9.2' type='checkbox'  value='Return For Hygiene Only'  id='choice_2_9_2' tabindex='31'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_2' id='label_2_9_2'>Return For Hygiene Only<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_9_3'>\n\t\t\t\t\t\t\t\t<input name='input_9.3' type='checkbox'  value='Patient Released'  id='choice_2_9_3' tabindex='32'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_9_3' id='label_2_9_3'>Patient Released<\/label>\n\t\t\t\t\t\t\t<\/li>\n<\/ul>\n<\/div>\n<\/li>\n<li id='field_2_17' class='gfield gsection field_sublabel_below field_description_below' >\n<h2 class='gsection_title'>Patient Evaluation<\/h2>\n<\/li>\n<li id='field_2_10' class='gfield gf_left_half field_sublabel_below field_description_below' ><label class='gfield_label'  >Please Evaluate Patient For:<\/label>\n<div class='ginput_container ginput_container_checkbox'>\n<ul class='gfield_checkbox' id='input_2_10'>\n<li class='gchoice_2_10_1'>\n\t\t\t\t\t\t\t\t<input name='input_10.1' type='checkbox'  value='Esthetic Evaluation'  id='choice_2_10_1' tabindex='33'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_1' id='label_2_10_1'>Esthetic Evaluation<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_2'>\n\t\t\t\t\t\t\t\t<input name='input_10.2' type='checkbox'  value='Wear\/Erosion'  id='choice_2_10_2' tabindex='34'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_2' id='label_2_10_2'>Wear\/Erosion<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_3'>\n\t\t\t\t\t\t\t\t<input name='input_10.3' type='checkbox'  value='Vertical Dimension Compromise'  id='choice_2_10_3' tabindex='35'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_3' id='label_2_10_3'>Vertical Dimension Compromise<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_4'>\n\t\t\t\t\t\t\t\t<input name='input_10.4' type='checkbox'  value='Failing Fixed Prosthetics'  id='choice_2_10_4' tabindex='36'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_4' id='label_2_10_4'>Failing Fixed Prosthetics<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_5'>\n\t\t\t\t\t\t\t\t<input name='input_10.5' type='checkbox'  value='Rampant Caries'  id='choice_2_10_5' tabindex='37'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_5' id='label_2_10_5'>Rampant Caries<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_6'>\n\t\t\t\t\t\t\t\t<input name='input_10.6' type='checkbox'  value='Tooth Restorability'  id='choice_2_10_6' tabindex='38'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_6' id='label_2_10_6'>Tooth Restorability<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_7'>\n\t\t\t\t\t\t\t\t<input name='input_10.7' type='checkbox'  value='Matching Single Central\/Anterior Tooth'  id='choice_2_10_7' tabindex='39'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_7' id='label_2_10_7'>Matching Single Central\/Anterior Tooth<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_8'>\n\t\t\t\t\t\t\t\t<input name='input_10.8' type='checkbox'  value='Missing Tooth\/Teeth'  id='choice_2_10_8' tabindex='40'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_8' id='label_2_10_8'>Missing Tooth\/Teeth<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_9'>\n\t\t\t\t\t\t\t\t<input name='input_10.9' type='checkbox'  value='Dental Implant Surgery'  id='choice_2_10_9' tabindex='41'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_9' id='label_2_10_9'>Dental Implant Surgery<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_11'>\n\t\t\t\t\t\t\t\t<input name='input_10.11' type='checkbox'  value='Fractured\/Ill-fitting Removable Prosthetic'  id='choice_2_10_11' tabindex='42'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_11' id='label_2_10_11'>Fractured\/Ill-fitting Removable Prosthetic<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_12'>\n\t\t\t\t\t\t\t\t<input name='input_10.12' type='checkbox'  value='Sleep Apnea'  id='choice_2_10_12' tabindex='43'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_12' id='label_2_10_12'>Sleep Apnea<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_13'>\n\t\t\t\t\t\t\t\t<input name='input_10.13' type='checkbox'  value='TMJ Disorder'  id='choice_2_10_13' tabindex='44'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_13' id='label_2_10_13'>TMJ Disorder<\/label>\n\t\t\t\t\t\t\t<\/li>\n<li class='gchoice_2_10_14'>\n\t\t\t\t\t\t\t\t<input name='input_10.14' type='checkbox'  value='Oral\/Maxillofacial defect'  id='choice_2_10_14' tabindex='45'  \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_10_14' id='label_2_10_14'>Oral\/Maxillofacial 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