{"id":267,"date":"2018-05-14T13:17:33","date_gmt":"2018-05-14T12:17:33","guid":{"rendered":"https:\/\/code.v-forms.net\/?page_id=267"},"modified":"2024-03-18T17:48:44","modified_gmt":"2024-03-18T17:48:44","slug":"home","status":"publish","type":"page","link":"https:\/\/rumneyhilldental.v-forms.net\/cy\/","title":{"rendered":"Cartref"},"content":{"rendered":"\n\t<section class=\"section\" id=\"section_980487980\">\n\t\t<div class=\"section-bg fill\" >\n\t\t\t\t\t\t\t\t\t\n\t\t\t\n\n\t\t<\/div>\n\n\t\t\n\n\t\t<div class=\"section-content relative\">\n\t\t\t\n\n  <div class=\"banner has-hover\" id=\"banner-1263235369\">\n          <div class=\"banner-inner fill\">\n        <div class=\"banner-bg fill\" >\n                                                \n                    <\/div>\n\t\t\n\t<div class=\"ux-shape-divider ux-shape-divider--bottom ux-shape-divider--style-curve\">\n\t\t<svg viewBox=\"0 0 1000 100\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" preserveAspectRatio=\"none\">\n\t<path class=\"ux-shape-fill\" d=\"M0 0C0 0 200 50 500 50C800 50 1000 0 1000 0V101H0V1V0Z\"\/>\n<\/svg>\n\t<\/div>\n        <div class=\"banner-layers container\">\n            <div class=\"fill banner-link\"><\/div>            \n   <div id=\"text-box-921975179\" class=\"text-box banner-layer x50 md-x50 lg-x50 y5 md-y10 lg-y10 res-text\">\n                                <div class=\"text-box-content text dark\">\n              \n              <div class=\"text-inner text-center\">\n                  \n\t<div id=\"text-1985692152\" class=\"text\">\n\t\t\n<h1 style=\"font-weight: 700;\">Refer a patient to Rumney Endodontics &amp; Dental Care<\/h1>\n\t\t\n<style>\n#text-1985692152 {\n  font-size: 0.75rem;\n}\n@media (min-width:550px) {\n  #text-1985692152 {\n    font-size: 0.8rem;\n  }\n}\n<\/style>\n\t<\/div>\n\t\n              <\/div>\n           <\/div>\n                            \n<style>\n#text-box-921975179 {\n  width: 90%;\n}\n#text-box-921975179 .text-box-content {\n  font-size: 100%;\n}\n@media (min-width:850px) {\n  #text-box-921975179 {\n    width: 60%;\n  }\n}\n<\/style>\n    <\/div>\n \n   <div id=\"text-box-1661022159\" class=\"text-box banner-layer x50 md-x50 lg-x50 y50 md-y50 lg-y50 res-text\">\n                                <div class=\"text-box-content text dark\">\n              \n              <div class=\"text-inner text-center\">\n                  \n<p>Your referrals are the highest compliments we can receive, and we are committed to delivering the same exceptional care and support to those you recommend to us. Thank you for being a part of our extended family and for helping us grow through your confidence in our services.<\/p>\n              <\/div>\n           <\/div>\n                            \n<style>\n#text-box-1661022159 {\n  width: 90%;\n}\n#text-box-1661022159 .text-box-content {\n  font-size: 100%;\n}\n@media (min-width:550px) {\n  #text-box-1661022159 {\n    width: 70%;\n  }\n}\n<\/style>\n    <\/div>\n \n        <\/div>\n      <\/div>\n\n            \n<style>\n#banner-1263235369 {\n  padding-top: 500px;\n  background-color: rgb(0, 83, 96);\n}\n#banner-1263235369 .ux-shape-divider--bottom svg {\n  height: 150px;\n  --divider-width: 100%;\n}\n<\/style>\n  <\/div>\n\n\n\t\t<\/div>\n\n\t\t\n<style>\n#section_980487980 {\n  padding-top: 0px;\n  padding-bottom: 0px;\n}\n<\/style>\n\t<\/section>\n\t\n\t<div id=\"gap-850723607\" class=\"gap-element clearfix\" style=\"display:block; height:auto;\">\n\t\t\n<style>\n#gap-850723607 {\n  padding-top: 30px;\n}\n<\/style>\n\t<\/div>\n\t\n<div class=\"row\"  id=\"row-396131938\">\n\n\t<div id=\"col-102376760\" class=\"col small-12 large-12\"  >\n\t\t\t\t<div class=\"col-inner\" style=\"background-color:rgb(243, 243, 243);\" >\n\t\t\t\n\t\t\t\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n\n\/\/----------------------------------------------------------\n\/\/------ JAVASCRIPT HOOK FUNCTIONS FOR GRAVITY FORMS -------\n\/\/----------------------------------------------------------\n\nif ( ! gform ) {\n\tdocument.addEventListener( 'gform_main_scripts_loaded', function() { gform.scriptsLoaded = true; } );\n\tdocument.addEventListener( 'gform\/theme\/scripts_loaded', function() { gform.themeScriptsLoaded = true; } );\n\twindow.addEventListener( 'DOMContentLoaded', function() { gform.domLoaded = true; } );\n\n\tvar gform = {\n\t\tdomLoaded: false,\n\t\tscriptsLoaded: false,\n\t\tthemeScriptsLoaded: false,\n\t\tisFormEditor: () => typeof InitializeEditor === 'function',\n\n\t\t\/**\n\t\t * @deprecated 2.9 the use of initializeOnLoaded in the form editor context is deprecated.\n\t\t * @remove-in 4.0 this function will not check for gform.isFormEditor().\n\t\t *\/\n\t\tcallIfLoaded: function ( fn ) {\n\t\t\tif ( gform.domLoaded && gform.scriptsLoaded && ( gform.themeScriptsLoaded || gform.isFormEditor() ) ) {\n\t\t\t\tif ( gform.isFormEditor() ) {\n\t\t\t\t\tconsole.warn( 'The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.' );\n\t\t\t\t}\n\t\t\t\tfn();\n\t\t\t\treturn true;\n\t\t\t}\n\t\t\treturn false;\n\t\t},\n\n\t\t\/**\n\t\t * Call a function when all scripts are loaded\n\t\t *\n\t\t * @param function fn the callback function to call when all scripts are loaded\n\t\t *\n\t\t * @returns void\n\t\t *\/\n\t\tinitializeOnLoaded: function( fn ) {\n\t\t\tif ( ! gform.callIfLoaded( fn ) ) {\n\t\t\t\tdocument.addEventListener( 'gform_main_scripts_loaded', () => { gform.scriptsLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t\tdocument.addEventListener( 'gform\/theme\/scripts_loaded', () => { gform.themeScriptsLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t\twindow.addEventListener( 'DOMContentLoaded', () => { gform.domLoaded = true; gform.callIfLoaded( fn ); } );\n\t\t\t}\n\t\t},\n\n\t\thooks: { action: {}, filter: {} },\n\t\taddAction: function( action, callable, priority, tag ) {\n\t\t\tgform.addHook( 'action', action, callable, priority, tag );\n\t\t},\n\t\taddFilter: function( action, callable, priority, tag ) {\n\t\t\tgform.addHook( 'filter', action, callable, priority, tag );\n\t\t},\n\t\tdoAction: function( action ) {\n\t\t\tgform.doHook( 'action', action, arguments );\n\t\t},\n\t\tapplyFilters: function( action ) {\n\t\t\treturn gform.doHook( 'filter', action, arguments );\n\t\t},\n\t\tremoveAction: function( action, tag ) {\n\t\t\tgform.removeHook( 'action', action, tag );\n\t\t},\n\t\tremoveFilter: function( action, priority, tag ) {\n\t\t\tgform.removeHook( 'filter', action, priority, tag );\n\t\t},\n\t\taddHook: function( hookType, action, callable, priority, tag ) {\n\t\t\tif ( undefined == gform.hooks[hookType][action] ) {\n\t\t\t\tgform.hooks[hookType][action] = [];\n\t\t\t}\n\t\t\tvar hooks = gform.hooks[hookType][action];\n\t\t\tif ( undefined == tag ) {\n\t\t\t\ttag = action + '_' + hooks.length;\n\t\t\t}\n\t\t\tif( priority == undefined ){\n\t\t\t\tpriority = 10;\n\t\t\t}\n\n\t\t\tgform.hooks[hookType][action].push( { tag:tag, callable:callable, priority:priority } );\n\t\t},\n\t\tdoHook: function( hookType, action, args ) {\n\n\t\t\t\/\/ splice args from object into array and remove first index which is the hook name\n\t\t\targs = Array.prototype.slice.call(args, 1);\n\n\t\t\tif ( undefined != gform.hooks[hookType][action] ) {\n\t\t\t\tvar hooks = gform.hooks[hookType][action], hook;\n\t\t\t\t\/\/sort by priority\n\t\t\t\thooks.sort(function(a,b){return a[\"priority\"]-b[\"priority\"]});\n\n\t\t\t\thooks.forEach( function( hookItem ) {\n\t\t\t\t\thook = hookItem.callable;\n\n\t\t\t\t\tif(typeof hook != 'function')\n\t\t\t\t\t\thook = window[hook];\n\t\t\t\t\tif ( 'action' == hookType ) {\n\t\t\t\t\t\thook.apply(null, args);\n\t\t\t\t\t} else {\n\t\t\t\t\t\targs[0] = hook.apply(null, args);\n\t\t\t\t\t}\n\t\t\t\t} );\n\t\t\t}\n\t\t\tif ( 'filter'==hookType ) {\n\t\t\t\treturn args[0];\n\t\t\t}\n\t\t},\n\t\tremoveHook: function( hookType, action, priority, tag ) {\n\t\t\tif ( undefined != gform.hooks[hookType][action] ) {\n\t\t\t\tvar hooks = gform.hooks[hookType][action];\n\t\t\t\thooks = hooks.filter( function(hook, index, arr) {\n\t\t\t\t\tvar removeHook = (undefined==tag||tag==hook.tag) && (undefined==priority||priority==hook.priority);\n\t\t\t\t\treturn !removeHook;\n\t\t\t\t} );\n\t\t\t\tgform.hooks[hookType][action] = hooks;\n\t\t\t}\n\t\t}\n\t};\n}\n\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_24' style='display:none'><div id='gf_24' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_24' id='gform_24'  action='\/cy\/wp-json\/wp\/v2\/pages\/267#gf_24' data-formid='24' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_24' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_24_9\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Patient Details<\/h2><\/div><fieldset id=\"field_24_36\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_24_36'>\n                            \n                            <span id='input_24_36_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.3' id='input_24_36_3' value=''   aria-required='true'   placeholder='First Name'  \/>\n                                                    <label for='input_24_36_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_24_36_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_36.6' id='input_24_36_6' value=''   aria-required='true'   placeholder='Surname'  \/>\n                                                    <label for='input_24_36_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Surname<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_24_37\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_37'>Patient Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_37' id='input_24_37' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_24_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_4'>Patient Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_24_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_24_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_24_3' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_24_3_2_container'>\n                                            <input type='number' maxlength='2' name='input_3[]' id='input_24_3_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_24_3_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_24_3_1_container'>\n                                        <input type='number' maxlength='2' name='input_3[]' id='input_24_3_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_24_3_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_24_3_3_container'>\n                                        <input type='number' maxlength='4' name='input_3[]' id='input_24_3_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_24_3_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><fieldset id=\"field_24_66\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Patient Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_24_66' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_24_66_1_container' >\n                                        <input type='text' name='input_66.1' id='input_24_66_1' value=''   placeholder='Street Address' aria-required='true'    \/>\n                                        <label for='input_24_66_1' id='input_24_66_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_24_66_2_container' >\n                                        <input type='text' name='input_66.2' id='input_24_66_2' value=''   placeholder='Address Line 2'  aria-required='false'   \/>\n                                        <label for='input_24_66_2' id='input_24_66_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_24_66_3_container' >\n                                    <input type='text' name='input_66.3' id='input_24_66_3' value=''   placeholder='City' aria-required='true'    \/>\n                                    <label for='input_24_66_3' id='input_24_66_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_66.4' id='input_24_66_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_24_66_5_container' >\n                                    <input type='text' name='input_66.5' id='input_24_66_5' value=''   placeholder='Post Code' aria-required='true'    \/>\n                                    <label for='input_24_66_5' id='input_24_66_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_66.6' id='input_24_66_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_24_10\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Referring Dentist<\/h2><\/div><div id=\"field_24_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_11'>Dentist Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_24_11' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_67'>Practice Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_24_67' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_12'>Dentist Telephone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_24_12' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_14\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_14'>Dentist Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_24_14' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_24_68\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Practice Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_24_68' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_24_68_1_container' >\n                                        <input type='text' name='input_68.1' id='input_24_68_1' value=''   placeholder='Street Address' aria-required='true'    \/>\n                                        <label for='input_24_68_1' id='input_24_68_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_24_68_2_container' >\n                                        <input type='text' name='input_68.2' id='input_24_68_2' value=''   placeholder='Address Line 2'  aria-required='false'   \/>\n                                        <label for='input_24_68_2' id='input_24_68_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_24_68_3_container' >\n                                    <input type='text' name='input_68.3' id='input_24_68_3' value=''   placeholder='City' aria-required='true'    \/>\n                                    <label for='input_24_68_3' id='input_24_68_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_68.4' id='input_24_68_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_24_68_5_container' >\n                                    <input type='text' name='input_68.5' id='input_24_68_5' value=''   placeholder='Post Code' aria-required='true'    \/>\n                                    <label for='input_24_68_5' id='input_24_68_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_68.6' id='input_24_68_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_24_33\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Referral Details<\/h2><\/div><div id=\"field_24_17\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_17'>Referral Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_24_17' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_24_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Preferred Endodontist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_70'>\n\t\t\t<div class='gchoice gchoice_24_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Dr Andrew Bartley BDS (Wales) 2005 MJDF PG Dip (Endo)'  id='choice_24_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_70_0' id='label_24_70_0' class='gform-field-label gform-field-label--type-inline'>Dr Andrew Bartley BDS (Wales) 2005 MJDF PG Dip (Endo)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Dr Cassandra Maunder BDS (Wales) 2006. PG Dip (Endo)'  id='choice_24_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_70_1' id='label_24_70_1' class='gform-field-label gform-field-label--type-inline'>Dr Cassandra Maunder BDS (Wales) 2006. PG Dip (Endo)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Dr Jessica Morrick BDS (Wales) 2016 PG Dip'  id='choice_24_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_70_2' id='label_24_70_2' class='gform-field-label gform-field-label--type-inline'>Dr Jessica Morrick BDS (Wales) 2016 PG Dip<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_70_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Dr Joshua Scaife BDS (Wales) 2016 PG Dip'  id='choice_24_70_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_70_3' id='label_24_70_3' class='gform-field-label gform-field-label--type-inline'>Dr Joshua Scaife BDS (Wales) 2016 PG Dip<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_70_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No preference (all treating dentists have a special interest in endodontics)'  id='choice_24_70_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_70_4' id='label_24_70_4' class='gform-field-label gform-field-label--type-inline'>No preference (all treating dentists have a special interest in endodontics)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_24_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Referral Options<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_71'>\n\t\t\t<div class='gchoice gchoice_24_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='CBCT'  id='choice_24_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_71_0' id='label_24_71_0' class='gform-field-label gform-field-label--type-inline'>CBCT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='OPT'  id='choice_24_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_71_1' id='label_24_71_1' class='gform-field-label gform-field-label--type-inline'>OPT<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_71_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Extraoral Bitewing'  id='choice_24_71_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_71_2' id='label_24_71_2' class='gform-field-label gform-field-label--type-inline'>Extraoral Bitewing<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_72\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>CBCT\/OPT Details<\/h2>\n<p>In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental CBCT scan and the scan must be clinically evaluated by someone trained in the analysis of dental CBCT scans.<\/p><\/div><fieldset id=\"field_24_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Confirmation of Irmer Referrer Training<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_78'>\n\t\t\t<div class='gchoice gchoice_24_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_24_78_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_24_78\"   \/>\n\t\t\t\t\t<label for='choice_24_78_0' id='label_24_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_24_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_78_1' id='label_24_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_24_78'>I have undertaken training required to satisfy the minimum criteria as an Irmer Referrer \/ Conebeam CT which is covered on pages 49, 50 and 51 of the Guidance of Safe Use of Dental Cone Beam CT (Computed Tomography) Equipment prepared by the HPA Working Party on Dental Cone Beam CT Equipment. (<a href=\"http:\/\/www.hpa.org.uk\/webc\/HPAwebFile\/HPAweb_C\/1287143862981\" target=\"_blank\">Click to read guidance notes<\/a>)<\/div><\/fieldset><fieldset id=\"field_24_73\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Region to be scanned<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_24_73'><div class='gchoice gchoice_24_73_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.1' type='checkbox'  value='CBCT for Endodontics'  id='choice_24_73_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_73_1' id='label_24_73_1' class='gform-field-label gform-field-label--type-inline'>CBCT for Endodontics<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_73_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.2' type='checkbox'  value='Mandible'  id='choice_24_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_73_2' id='label_24_73_2' class='gform-field-label gform-field-label--type-inline'>Mandible<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_73_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.3' type='checkbox'  value='Maxilla'  id='choice_24_73_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_73_3' id='label_24_73_3' class='gform-field-label gform-field-label--type-inline'>Maxilla<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_73_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.4' type='checkbox'  value='Both'  id='choice_24_73_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_73_4' id='label_24_73_4' class='gform-field-label gform-field-label--type-inline'>Both<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_73_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.5' type='checkbox'  value='External Bitewing'  id='choice_24_73_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_73_5' id='label_24_73_5' class='gform-field-label gform-field-label--type-inline'>External Bitewing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_73_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.6' type='checkbox'  value='OPT'  id='choice_24_73_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_73_6' id='label_24_73_6' class='gform-field-label gform-field-label--type-inline'>OPT<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_74\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_74'>Reason for Referral and Justification for the scan<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_74' id='input_24_74' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_24_75\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_75'>Special Instructions to IRMER operator involved in scan acquisition<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_24_75' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_24_76\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_76'>Images will be reviewed and findings recorded by an IRMER operator (reporter) either<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_24_76' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' >Please select<\/option><option value='Me' >Me<\/option><option value='Rumney Endodontics Dentist' >Rumney Endodontics Dentist<\/option><\/select><\/div><\/div><fieldset id=\"field_24_77\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select treatment option &amp; pricing<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_24_77'><div class='gchoice gchoice_24_77_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.1' type='checkbox'  value='Dental CBCT Scan for small volume or one jaw \u00a390'  id='choice_24_77_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_77_1' id='label_24_77_1' class='gform-field-label gform-field-label--type-inline'>Dental CBCT Scan for small volume or one jaw \u00a390<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_77_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.2' type='checkbox'  value='Dental CBCT Scan of both jaws \u00a3150'  id='choice_24_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_77_2' id='label_24_77_2' class='gform-field-label gform-field-label--type-inline'>Dental CBCT Scan of both jaws \u00a3150<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_77_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.3' type='checkbox'  value='Radiology Reporting (if required) - \u00a360'  id='choice_24_77_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_77_3' id='label_24_77_3' class='gform-field-label gform-field-label--type-inline'>Radiology Reporting (if required) - \u00a360<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_77_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.4' type='checkbox'  value='OPT- \u00a390'  id='choice_24_77_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_77_4' id='label_24_77_4' class='gform-field-label gform-field-label--type-inline'>OPT- \u00a390<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_77_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_77.5' type='checkbox'  value='External bitewing- \u00a390'  id='choice_24_77_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_77_5' id='label_24_77_5' class='gform-field-label gform-field-label--type-inline'>External bitewing- \u00a390<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_69\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_24_69'>Medical History<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_69' id='input_24_69' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_24_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have additional files to upload in support of this referral?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_24'>\n\t\t\t<div class='gchoice gchoice_24_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_24_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_24_0' id='label_24_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_24_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_24_1' id='label_24_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_21\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_24_21'>File Attachments<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_24_21' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_24_21&quot;,&quot;container&quot;:&quot;gform_multifile_upload_24_21&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_24_21&quot;,&quot;filelist&quot;:&quot;gform_preview_24_21&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/rumneyhilldental.v-forms.net\\\/?gf_page=226df0252d4a532&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/rumneyhilldental.v-forms.net\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/rumneyhilldental.v-forms.net\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;jpg,pdf,doc,docx,png,jpeg&quot;}],&quot;max_file_size&quot;:&quot;536870912b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:24,&quot;field_id&quot;:21,&quot;_gform_file_upload_nonce_24_21&quot;:&quot;92ecd04c6a&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_24_21&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_24_21' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_24_21' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_24_21\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_24_21'>Accepted file types: jpg, pdf, doc, docx, png, jpeg, Max. file size: 512 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_24_21'><\/ul> <div id='gform_preview_24_21' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_24_39\" class=\"gfield gfield--type-signature gfield--input-type-signature field_sublabel_below gfield--no-description field_description_below field_validation_below 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