{"id":303,"date":"2020-11-05T19:06:13","date_gmt":"2020-11-05T19:06:13","guid":{"rendered":"https:\/\/www.orthoville.ca\/refer-a-patient\/"},"modified":"2021-02-17T14:30:36","modified_gmt":"2021-02-17T14:30:36","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/www.orthoville.ca\/en\/refer-a-patient\/","title":{"rendered":"Refer a Patient"},"content":{"rendered":"\n<div class=\"wp-block-group bg-primary-200\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<div class=\"wp-block-group container-md text-white\"><div class=\"wp-block-group__inner-container is-layout-flow wp-block-group-is-layout-flow\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1330-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"1330\">\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\/303#wpcf7-f1330-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1330\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1330-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<div>\n<h2>Choose your clinic*<\/h2>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-clinics\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-clinics\" value=\"Blainville\" \/><span class=\"wpcf7-list-item-label\">Blainville<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-clinics\" value=\"Montr\u00e9al (Westmount, NDG)\" \/><span class=\"wpcf7-list-item-label\">Montr\u00e9al (Westmount, NDG)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-clinics\" value=\"Terrebonne\" \/><span class=\"wpcf7-list-item-label\">Terrebonne<\/span><\/label><\/span><\/span><\/span>\n<\/div><br>\n<h2 class=\"mb-3\">Patient Information<\/h2>\n\n<div class=\"flex sm:flex-col\">\n\n<div class=\"c-floating-text-field mr-2 sm:mr-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required c-floating-text-field__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-first-name\" \/><\/span>\n<label class=\"c-floating-text-field__label\">Patient's first name *<\/label>\n<\/div>\n\n<div class=\"c-floating-text-field ml-2 sm:ml-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required c-floating-text-field__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-last-name\" \/><\/span>\n<label class=\"c-floating-text-field__label\">Patient's name *<\/label>\n<\/div>\n\n<\/div>\n\n<div class=\"flex sm:flex-col\">\n\n<div class=\"c-floating-text-field mr-2 sm:mr-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel c-floating-text-field__input\" id=\"phone\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phone\" \/><\/span>\n<label class=\"c-floating-text-field__label\">Patient's phone number *<\/label>\n<\/div>\n\n<div class=\"c-floating-text-field ml-2 sm:ml-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required c-floating-text-field__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-city\" \/><\/span>\n<label class=\"c-floating-text-field__label\">City *<\/label>\n<\/div>\n\n<\/div>\n<h4>Parent's name if minor patient<\/h4>\n<div class=\"flex mt-4 sm:flex-col\">\n\n<div class=\"c-floating-text-field mr-2 sm:mr-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"prenom-parent\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text c-floating-text-field__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"prenom-parent\" \/><\/span>\n<label class=\"c-floating-text-field__label\">Parent first name<\/label>\n<\/div>\n\n<div class=\"c-floating-text-field ml-2 sm:ml-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom-parent\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text c-floating-text-field__input\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom-parent\" \/><\/span>\n<label class=\"c-floating-text-field__label\">Parent last name<\/label>\n<\/div>\n<\/div>\n<div class=\"mb-4\">\n<h4 class=\"mt-0\">Date of birth *<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date-naissance\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required date-field c-text-field\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"date-naissance\" \/><\/span>\n<\/div>\n\n<div class=\"flex sm:flex-col\">\n\n<div class=\"c-floating-text-field mr-2 sm:mr-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dentist-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required c-floating-text-field__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"dentist-name\" \/><\/span>\n<label class=\"c-floating-text-field__label\">Name of the referring dentist *<\/label>\n<\/div>\n\n<div class=\"c-floating-text-field ml-2 sm:ml-0\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dentist-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email c-floating-text-field__input\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"dentist-email\" \/><\/span>\n<label class=\"c-floating-text-field__label\">E-mail of the referring dentist *<\/label>\n<\/div>\n\n<\/div>\n\n<h2 class=\"mb-3\">Additional information<\/h2>\n\n<div class=\"c-textarea mb-4\">\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-precisions\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea c-textarea__input\" aria-invalid=\"false\" name=\"your-precisions\"><\/textarea><\/span> \n<label class=\"c-textarea__label\">Enter your details here<\/label>\n<\/div>\n\n<div class=\"mb-4\">\n<h4>Communication with the patient<\/h4>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"radio-patient\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-patient\" value=\"Please call the patient\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Please call the patient<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-patient\" value=\"The patient will contact you\" \/><span class=\"wpcf7-list-item-label\">The patient will contact you<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n\n<div class=\"mb-2\">\n<h4>Imaging (X-rays, photos)<\/h4>\n<p class=\"c-typography--body2 opacity-80 mb-2\">.jpg, .pdf, .txt formats, 10 megabyte maximum<\/p>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"upload-file-images\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-drag-n-drop-file d-none\" aria-invalid=\"false\" type=\"file\" multiple=\"multiple\" data-name=\"upload-file-images\" data-type=\"jpg|pdf|txt|jpeg|png\" data-limit=\"100000000\" data-max=\"3\" data-id=\"1330\" data-version=\"free version 1.3.8.7\" accept=\".jpg, .pdf, .txt, .jpeg, .png\" \/><\/span>\n<\/div>\n<h4>You're not digital?<\/h4>\n<p>It's easy, just take a picture of your x-ray with a smartphone and email it to yourself. Then download this image to your computer. From this form, select this image. Repeat this procedure for all your x-rays and photos.<\/p>\n\n<div class=\"mt-4 text-center\">\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner c-btn c-btn--outlined\" type=\"submit\" value=\"Send\" \/>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n\n\n\n<p><\/p>\n<\/div><\/div>\n<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":551,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-303","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.4 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Referring a patient to the orthodontist | Orthoville Clinic<\/title>\n<meta name=\"description\" content=\"Refer a patient to the Orthoville 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