{"id":2284,"date":"2022-02-12T07:14:47","date_gmt":"2022-02-12T12:14:47","guid":{"rendered":"https:\/\/www.gtaperio.com\/?page_id=2284"},"modified":"2024-10-16T12:06:07","modified_gmt":"2024-10-16T16:06:07","slug":"on-line-referral","status":"publish","type":"page","link":"https:\/\/www.gtaperio.com\/?page_id=2284","title":{"rendered":"On-Line Referral"},"content":{"rendered":"\n<p>Please fill in the referral below and our team will contact your patient to schedule an appointment.  Please e-mail any additional information\/attachments to info@gtaperio.com.  <\/p>\n\n\n<div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-1099ac9a-91df-45ab-853b-f22d54096744\" id=\"wpforms-2298\"><form id=\"wpforms-form-2298\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2298\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2284&#038;wpforms_form_id=2298\" data-token=\"4172b518f31380aa5e88c7e02cefceb9\" data-token-time=\"1775981192\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-2298-field_7-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"7\"><label class=\"wpforms-field-label\">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-2298-field_7\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][7][first]\" required><label for=\"wpforms-2298-field_7\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-2298-field_7-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][7][last]\" required><label for=\"wpforms-2298-field_7-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-2298-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_8\">Patient Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2298-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" required><\/div><div id=\"wpforms-2298-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_9\">Patient E-mail:<\/label><input type=\"text\" id=\"wpforms-2298-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-2298-field_4-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_4\">Purpose of Referral <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-2298-field_4\" class=\"wpforms-field-small wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-small\" data-search-enabled=\"\" name=\"wpforms[fields][4]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'><\/option><option value=\"Periodontal Consult\"  class=\"choice-3 depth-1\"  >Periodontal Consult<\/option><option value=\"Endo Consult\"  class=\"choice-4 depth-1\"  >Endo Consult<\/option><option value=\"Prostho Consult\"  class=\"choice-6 depth-1\"  >Prostho Consult<\/option><option value=\"Gum Recession Consult\"  class=\"choice-2 depth-1\"  >Gum Recession Consult<\/option><option value=\"Dental Implant Consult\"  class=\"choice-1 depth-1\"  >Dental Implant Consult<\/option><option value=\"cbCT (specify location and if measurements needed below)\"  class=\"choice-5 depth-1\"  >cbCT (specify location and if measurements needed below)<\/option><\/select><\/div><div id=\"wpforms-2298-field_17-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_17\">Preferred Doctor for patient to see: <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-2298-field_17\" class=\"wpforms-field-medium wpforms-field-required choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][17]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'><\/option><option value=\"First Available Periodontist\"  class=\"choice-1 depth-1\"  >First Available Periodontist<\/option><option value=\"Dr. Reza Termei - Perio\"  class=\"choice-3 depth-1\"  >Dr. Reza Termei &#8211; Perio<\/option><option value=\"Dr. Jaffer Kermalli - Perio\"  class=\"choice-4 depth-1\"  >Dr. Jaffer Kermalli &#8211; Perio<\/option><option value=\"Dr. Dina Zahedi - Perio\"  class=\"choice-5 depth-1\"  >Dr. Dina Zahedi &#8211; Perio<\/option><option value=\"Dr. Shawn Robinson - Perio\"  class=\"choice-6 depth-1\"  >Dr. Shawn Robinson &#8211; Perio<\/option><option value=\"First Available Endodontist\"  class=\"choice-2 depth-1\"  >First Available Endodontist<\/option><option value=\"Dr. Amir Azarpazhooh - Endo\"  class=\"choice-7 depth-1\"  >Dr. Amir Azarpazhooh &#8211; Endo<\/option><option value=\"Dr. Annie Shrestha - Endo\"  class=\"choice-8 depth-1\"  >Dr. Annie Shrestha &#8211; Endo<\/option><option value=\"Dr. Majid Zakeri - Prostho\"  class=\"choice-9 depth-1\"  >Dr. Majid Zakeri &#8211; Prostho<\/option><option value=\"Dr. Elahe Behrooz - Prostho\"  class=\"choice-11 depth-1\"  >Dr. Elahe Behrooz &#8211; Prostho<\/option><option value=\"Haseeb Hafeez - Denturist\"  class=\"choice-10 depth-1\"  >Haseeb Hafeez &#8211; Denturist<\/option><\/select><\/div><div id=\"wpforms-2298-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_2\">Referring Dentist\/Practitioner <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2298-field_2\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/div><div id=\"wpforms-2298-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_3\">Referral Contact Info (i.e. your e-mail and\/or phone #) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2298-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-2298-field_10-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_10\">Reason for referral (Specify tooth\/teeth): <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-2298-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/textarea><\/div><div id=\"wpforms-2298-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_12\">cbCT &#8211; Specify area of interest or which jaw to image and if measurements are required. <\/label><input type=\"text\" id=\"wpforms-2298-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" ><\/div><div id=\"wpforms-2298-field_19-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"19\"><label class=\"wpforms-field-label\">Does the patient have any relevant radiographs taken within the last 6 months? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-2298-field_19\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-2298-field_19_1\" name=\"wpforms[fields][19]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2298-field_19_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-2298-field_19_2\" name=\"wpforms[fields][19]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2298-field_19_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-2298-field_14-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_14\">Upload files. Please upload radiographs in .JPG format.<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"14\"\n\t\tdata-form-id=\"2298\"\n\t\tdata-input-name=\"wpforms_2298_14\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,svg\"\n\t\tdata-max-size=\"536870912\"\n\t\tdata-max-file-number=\"10\"\n\t\tdata-post-max-size=\"536870912\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg  viewBox=\"0 0 640 640\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M352 173.3L352 384C352 401.7 337.7 416 320 416C302.3 416 288 401.7 288 384L288 173.3L246.6 214.7C234.1 227.2 213.8 227.2 201.3 214.7C188.8 202.2 188.8 181.9 201.3 169.4L297.3 73.4C309.8 60.9 330.1 60.9 342.6 73.4L438.6 169.4C451.1 181.9 451.1 202.2 438.6 214.7C426.1 227.2 405.8 227.2 393.3 214.7L352 173.3zM320 464C364.2 464 400 428.2 400 384L480 384C515.3 384 544 412.7 544 448L544 480C544 515.3 515.3 544 480 544L160 544C124.7 544 96 515.3 96 480L96 448C96 412.7 124.7 384 160 384L240 384C240 428.2 275.8 464 320 464zM464 488C477.3 488 488 477.3 488 464C488 450.7 477.3 440 464 440C450.7 440 440 450.7 440 464C440 477.3 450.7 488 464 488z\"\/>\n\t\t<\/svg>\n\n\t\t<span class=\"modern-title\">\n\t\t\t\t\t\t\tDrag &amp; Drop Files, \t\t\t\t<span>Choose Files to Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 10 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"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;\"\n\t\tid=\"wpforms-2298-field_14\"\n\t\tname=\"wpforms_2298_14\" \t\tvalue=\"\">\n<\/div><div id=\"wpforms-2298-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-2298-field_16\">Date of radiograph<\/label><input type=\"text\" id=\"wpforms-2298-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"2298\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/www.gtaperio.com\/index.php?rest_route=\/wp\/v2\/pages\/2284\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-2298\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.gtaperio.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"<p>Please fill in the referral below and our team will contact your patient to schedule an appointment. Please e-mail any additional information\/attachments to info@gtaperio.com.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2284","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=\/wp\/v2\/pages\/2284","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2284"}],"version-history":[{"count":7,"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=\/wp\/v2\/pages\/2284\/revisions"}],"predecessor-version":[{"id":2434,"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=\/wp\/v2\/pages\/2284\/revisions\/2434"}],"wp:attachment":[{"href":"https:\/\/www.gtaperio.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2284"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}