{"id":12293,"date":"2015-07-13T14:20:47","date_gmt":"2015-07-13T14:20:47","guid":{"rendered":"http:\/\/woocommerce-242810-747202.cloudwaysapps.com\/en\/?page_id=12293"},"modified":"2020-10-05T13:37:01","modified_gmt":"2020-10-05T17:37:01","slug":"referal-form","status":"publish","type":"page","link":"https:\/\/paroimplanto.ca\/en\/referal-form","title":{"rendered":"Secure Online Referal Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container center nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:left top;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:20px;--awb-padding-right:0px;--awb-padding-bottom:20px;--awb-padding-left:0px;--awb-border-sizes-top:0px;--awb-border-sizes-bottom:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:calc( 1100px + 0px );margin-left: calc(-0px \/ 2 );margin-right: calc(-0px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column center\" style=\"--awb-bg-position:center top;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:20px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f12294-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/12293#wpcf7-f12294-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"12294\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f12294-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<link rel=\"stylesheet\" href=\"https:\/\/paroimplanto.ca\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/css\/frontend.css\" \/><script type=\"text\/javascript\" src=\"https:\/\/paroimplanto.ca\/wp-content\/plugins\/pdf-forms-for-contact-form-7\/js\/frontend.js?ver=2.1.10\"><\/script><h1>SECURE ONLINE REFERRAL FORM\n<\/h1>\n<h2>PATIENT INFORMATION\n<\/h2>\n<div id=\"two-column\" h-align=\"center\">\n\t<div id=\"left\">\n\t\t<p> Last name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t\t<\/p>\n\t\t<p> Home phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"home-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"home-phone\" \/><\/span>\n\t\t<\/p>\n\t\t<p>Cell phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cell-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cell-phone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"right\">\n\t\t<p> First name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t\t<\/p>\n\t\t<p>Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t\t<\/p>\n\t\t<p>Office phone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"office-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"office-phone\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<p><img decoding=\"async\" src=\"https:\/\/paroimplanto.ca\/wp-content\/uploads\/2015\/07\/spacer.png\" alt=\"spacer\" height=\"50px\" width=\"3%\" \/>\n\t<\/p>\n\t<h2>REFERRAL\n\t<\/h2>\n\t<div id=\"two-column\" h-align=\"center\">\n\t\t<div id=\"left\">\n\t\t\t<p> This patient is referred to (you can choose more than one):<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ref-a\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"ref-a[]\" value=\"First available\" \/><span class=\"wpcf7-list-item-label\">First available<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ref-a[]\" value=\"Dr Drouin\" \/><span class=\"wpcf7-list-item-label\">Dr Drouin<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ref-a[]\" value=\"Dr Tach\u00e9\" \/><span class=\"wpcf7-list-item-label\">Dr Tach\u00e9<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ref-a[]\" value=\"Dr Shenouda\" \/><span class=\"wpcf7-list-item-label\">Dr Shenouda<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"ref-a[]\" value=\"Dr Perri\" \/><span class=\"wpcf7-list-item-label\">Dr Perri<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"ref-a[]\" value=\"Dr Bernard\" \/><span class=\"wpcf7-list-item-label\">Dr Bernard<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p> Referred by :<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"ref-by\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ref-by\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p> Email :<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email-doc\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"email-doc\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p>File transfer:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file1\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"file2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file2\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"file3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file3\" \/><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"file4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file4\" \/><\/span>\n\t\t\t<\/p>\n\t\t\t<p> How would you like to receive the report ?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact_retour\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"contact_retour\" value=\"Email\" \/><span class=\"wpcf7-list-item-label\">Email<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"contact_retour\" value=\"Regular post\" \/><span class=\"wpcf7-list-item-label\">Regular post<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div id=\"right\">\n\t\t\t<p> Reason for reference:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"raison-check\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"raison-check[]\" value=\"Periodontics (periodontal pockets, bone grafting)\" \/><span class=\"wpcf7-list-item-label\">Periodontics (periodontal pockets, bone grafting)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"raison-check[]\" value=\"Gum graft\" \/><span class=\"wpcf7-list-item-label\">Gum graft<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"raison-check[]\" value=\"Specific periodontal surgery (clinical crown lengthening)\" \/><span class=\"wpcf7-list-item-label\">Specific periodontal surgery (clinical crown lengthening)<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"raison-check[]\" value=\"Laser (LANAP)\" \/><span class=\"wpcf7-list-item-label\">Laser (LANAP)<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"raison-check[]\" value=\"Implant\" \/><span class=\"wpcf7-list-item-label\">Implant<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<p> If implant,<br \/>\nType d'implant : <span class=\"wpcf7-form-control-wrap\" data-name=\"implant-menu\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"implant-menu\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"BIOMET 3i Encode\">BIOMET 3i Encode<\/option><option value=\"Astra\">Astra<\/option><option value=\"Straumann\">Straumann<\/option><option value=\"Ankylose\">Ankylose<\/option><\/select><\/span>\n\t\t\t<\/p>\n\t\t\t<p>Comment<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"remarque\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"remarque\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<p><img decoding=\"async\" src=\"https:\/\/paroimplanto.ca\/wp-content\/uploads\/2015\/07\/spacer.png\" alt=\"spacer\" height=\"50px\" width=\"7%\" \/>\n\t\t<\/p>\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"SUBMIT\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" 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