{"id":831,"date":"2022-06-07T18:04:26","date_gmt":"2022-06-07T18:04:26","guid":{"rendered":"https:\/\/kulshankidsdentistry.com\/?page_id=831"},"modified":"2024-03-09T01:23:17","modified_gmt":"2024-03-09T01:23:17","slug":"provider-referral","status":"publish","type":"page","link":"https:\/\/kulshankidsdentistry.com\/index.php\/provider-referral\/","title":{"rendered":"Provider Referral"},"content":{"rendered":"<div id=\"pl-831\"  class=\"panel-layout\" ><div id=\"pg-831-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-831-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-831-0-0-0\" class=\"so-panel widget widget_sow-editor panel-first-child panel-last-child\" data-index=\"0\" ><div class=\"so-widget-sow-editor so-widget-sow-editor-base\"><h3 class=\"widget-title\">PROVIDER REFERRAL <\/h3>\n<div class=\"siteorigin-widget-tinymce textwidget\">\n\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-829\"><form id=\"wpforms-form-829\" class=\"wpforms-validate wpforms-form\" data-formid=\"829\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/831\" data-token=\"93c998ad927eec3c82801268db420586\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-829-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_0\">Doctor name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-829-field_0\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][0]\" required><\/div><div id=\"wpforms-829-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_3\">Clinic name<\/label><input type=\"text\" id=\"wpforms-829-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" ><\/div><div id=\"wpforms-829-field_4-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_4\">Doctor\/Clinic telephone <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-829-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" placeholder=\"(---) --- ----\" required><\/div><div id=\"wpforms-829-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_1\">Doctor\/Clinic email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-829-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" placeholder=\"----@-----.---\" required><\/div><div id=\"wpforms-829-field_6-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_6\">Patient name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-829-field_6\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][6][first]\" required><label for=\"wpforms-829-field_6\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-829-field_6-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][6][last]\" required><label for=\"wpforms-829-field_6-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-829-field_7-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_7\">Patient DOB <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-829-field_7\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][7]\" required><\/div><div id=\"wpforms-829-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_5\">Parent\/Guardian name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-829-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" required><\/div><div id=\"wpforms-829-field_14-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_14\">Parent\/Guardian telephone  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-829-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" placeholder=\"(---) --- ----\" required><\/div><div id=\"wpforms-829-field_10-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_10\">Principal concern:  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-829-field_10\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_1\" name=\"wpforms[fields][10]\" value=\"Initial eval\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_1\">Initial eval<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_2\" name=\"wpforms[fields][10]\" value=\"OH habit\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_2\">OH habit<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_3\" name=\"wpforms[fields][10]\" value=\"OH exam\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_3\">OH exam<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_5\" name=\"wpforms[fields][10]\" value=\"Frenectomy\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_5\">Frenectomy<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_4\" name=\"wpforms[fields][10]\" value=\"Endo\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_4\">Endo<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_7\" name=\"wpforms[fields][10]\" value=\"Restorative\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_7\">Restorative<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_8\" name=\"wpforms[fields][10]\" value=\"Fluoride\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_8\">Fluoride<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_10_6\" name=\"wpforms[fields][10]\" value=\"Other\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_10_6\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-829-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_2\">Remarks: <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-829-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/textarea><\/div><div id=\"wpforms-829-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_11\">Images available: <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-829-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"Yes, sent via post mail\" >Yes, sent via post mail<\/option><option value=\"Yes, sent via email\" >Yes, sent via email<\/option><option value=\"No, unavailable\" >No, unavailable<\/option><\/select><\/div><div id=\"wpforms-829-field_12-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_12\">Return Patient after TX <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-829-field_12\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_12_1\" name=\"wpforms[fields][12]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_12_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_12_2\" name=\"wpforms[fields][12]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_12_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-829-field_15-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-829-field_15\">By providing patient contact information, I acknowledge patient (and\/or guardian) has given consent to receive SMS text messages from Kulshan Pediatric Dentistry (appointment reminders &amp; general two-way communications) Msg frequency varies. Msg &amp; data rates may apply.  NOTE: No marketing messages will be sent and information is NOT shared.  Patient (and\/or guardian) may always reply HELP for support or  STOP to opt out <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-829-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-829-field_15_1\" name=\"wpforms[fields][15]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-829-field_15_1\">Yes<\/label><\/li><\/ul><\/div><\/div><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha\" ><div class=\"g-recaptcha\" data-sitekey=\"6LdZ83waAAAAANufypxRy8y6dQ-0ntbMoF_zka_U\"><\/div><input type=\"text\" name=\"g-recaptcha-hidden\" class=\"wpforms-recaptcha-hidden\" style=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\" required><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"829\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"2\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-829\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<p>&nbsp;<\/p>\n<\/div>\n<\/div><\/div><\/div><div id=\"pgc-831-0-1\"  class=\"panel-grid-cell\" ><div id=\"panel-831-0-1-0\" class=\"so-panel widget widget_sow-editor panel-first-child panel-last-child\" data-index=\"1\" ><div class=\"so-widget-sow-editor so-widget-sow-editor-base\">\n<div class=\"siteorigin-widget-tinymce textwidget\">\n\t<h4><\/h4>\n<h5>For printable<\/h5>\n<h5>referral click<\/h5>\n<h5><a href=\"https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2024\/03\/KPD-printable-referral-2024.pdf\">HERE<\/a><\/h5>\n<h5><img loading=\"lazy\" class=\"alignnone wp-image-870\" src=\"https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2-297x300.png\" alt=\"\" width=\"75\" height=\"76\" srcset=\"https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2-297x300.png 297w, https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2-1013x1024.png 1013w, https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2-150x150.png 150w, https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2-768x776.png 768w, https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2-1519x1536.png 1519w, https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2-1200x1213.png 1200w, https:\/\/kulshankidsdentistry.com\/wp-content\/uploads\/2022\/06\/printer2.png 1899w\" sizes=\"(max-width: 75px) 100vw, 75px\" \/><\/h5>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>&nbsp; For printable referral click HERE &nbsp; &nbsp;<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/pages\/831"}],"collection":[{"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/comments?post=831"}],"version-history":[{"count":39,"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/pages\/831\/revisions"}],"predecessor-version":[{"id":1020,"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/pages\/831\/revisions\/1020"}],"wp:attachment":[{"href":"https:\/\/kulshankidsdentistry.com\/index.php\/wp-json\/wp\/v2\/media?parent=831"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}