{"id":859,"date":"2021-09-08T11:53:18","date_gmt":"2021-09-08T11:53:18","guid":{"rendered":"https:\/\/2021.malmin.co.uk\/?page_id=859"},"modified":"2021-09-08T12:44:47","modified_gmt":"2021-09-08T12:44:47","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/malmin.co.uk\/referrals\/refer-a-patient\/","title":{"rendered":"Referrals"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; background_enable_color=&#8221;off&#8221; background_image=&#8221;https:\/\/malmin.co.uk\/wp-content\/uploads\/2021\/09\/bg2-1600.jpg&#8221; custom_padding=&#8221;30px||30px||true|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; text_font_size=&#8221;20px&#8221; header_text_align=&#8221;center&#8221; header_text_color=&#8221;#00acdb&#8221; header_2_font_size=&#8221;25px&#8221; text_orientation=&#8221;center&#8221; custom_padding=&#8221;||20px||false|false&#8221; hover_enabled=&#8221;0&#8243; global_colors_info=&#8221;{}&#8221; sticky_enabled=&#8221;0&#8243;]<\/p>\n<h1>Our Referral Service<\/h1>\n<p>We welcome dentist referrals for Dental Implants, Sedation, Orthodontics, Restorative Dentistry, Endodontics, Periodontics and oral surgery. We hope you will be happy with the service we provide and the knowledge that your patients will always be returned to your care.<\/p>\n<p><strong>Simply fill in the form below,<a href=\"https:\/\/malmin.co.uk\/wp-content\/uploads\/2021\/09\/Malmin_Referral-Form_A4.pdf\">or\u00a0download and complete a pdf version<\/a>.<\/strong><\/p>\n<p><strong><a href=\"https:\/\/malmin.co.uk\/referrals\/nhs-ortho-referral\/\">For NHS orthodontic referrals CLICK HERE<\/a><\/strong>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; inner_shadow=&#8221;on&#8221; disabled_on=&#8221;off|off|off&#8221; _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; background_color=&#8221;#f5f5f5&#8243; module_alignment=&#8221;center&#8221; custom_margin=&#8221;0px||0px||false|false&#8221; custom_padding=&#8221;50px||70px||false|false&#8221; box_shadow_style=&#8221;preset1&#8243; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_code _builder_version=&#8221;4.10.6&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<div id=\"quform-98e039\" class=\"quform quform-1 quform-support-page-caching\"><form id=\"quform-form-98e039\" class=\"quform-form quform-form-1\" action=\"\/wp-json\/wp\/v2\/pages\/859\/#quform-98e039\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:1,&quot;uniqueId&quot;:&quot;98e039&quot;,&quot;theme&quot;:&quot;&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:{&quot;55&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;54&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Yes&quot;}]}},&quot;dependents&quot;:{&quot;54&quot;:[55]},&quot;elementIds&quot;:[55],&quot;dependentElementIds&quot;:[&quot;54&quot;],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:false,&quot;pages&quot;:[1],&quot;pageProgressType&quot;:&quot;numbers&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-1\"><input type=\"hidden\" name=\"quform_form_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"98e039\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/malmin.co.uk\/wp-json\/wp\/v2\/pages\/859\/\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"v2L0ZbKN7DGuKlmtGTmqQVqqAzhDmlxTL05yDfTt\" \/><div class=\"quform-elements quform-elements-1 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-element quform-element-page quform-page-1 quform-page-1_1 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-1_7 quform-cf\"><div class=\"quform-spacer\"><h2>Patient Details<\/h2><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_3 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_4\"><div class=\"quform-element quform-element-text quform-element-1_8 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_8\"><label class=\"quform-label-text\" for=\"quform_1_8_98e039\">First Name<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_8 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_8 quform-cf\"><input type=\"text\" id=\"quform_1_8_98e039\" name=\"quform_1_8\" class=\"quform-field quform-field-text quform-field-1_8\" placeholder=\"First Name\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_9 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_9\"><label class=\"quform-label-text\" for=\"quform_1_9_98e039\">Last Name<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_9 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_9 quform-cf\"><input type=\"text\" id=\"quform_1_9_98e039\" name=\"quform_1_9\" class=\"quform-field quform-field-text quform-field-1_9\" placeholder=\"Last Name\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-1_10 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_10\"><label class=\"quform-label-text\" for=\"quform_1_10_98e039\">Email Address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-1_10 quform-field-size-fat\"><div class=\"quform-input quform-input-email quform-input-1_10 quform-cf\"><input type=\"email\" id=\"quform_1_10_98e039\" name=\"quform_1_10\" class=\"quform-field quform-field-email quform-field-1_10\" placeholder=\"Email address\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_11 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_11\"><label class=\"quform-label-text\" for=\"quform_1_11_98e039\">Telephone Number<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_11 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_11 quform-cf\"><input type=\"text\" id=\"quform_1_11_98e039\" name=\"quform_1_11\" class=\"quform-field quform-field-text quform-field-1_11\" placeholder=\"Telephone Number\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-date quform-element-1_12 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_12\"><label class=\"quform-label-text\" for=\"quform_1_12_98e039\">Date of Birth<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-date quform-inner-1_12 quform-field-size-fat\"><div class=\"quform-input quform-input-date quform-input-1_12 quform-cf quform-has-field-icon-right\"><input type=\"text\" id=\"quform_1_12_98e039\" name=\"quform_1_12\" class=\"quform-field quform-field-date quform-field-1_12\" placeholder=\"YYYY-MM-DD\" data-options=\"{&quot;format&quot;:&quot;&quot;,&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;start&quot;:&quot;month&quot;,&quot;depth&quot;:&quot;month&quot;,&quot;showFooter&quot;:false,&quot;locale&quot;:&quot;en-US&quot;,&quot;placeholder&quot;:&quot;Date of Birth&quot;,&quot;autoOpen&quot;:true,&quot;identifier&quot;:&quot;1_12&quot;}\" \/><span class=\"quform-field-icon quform-field-icon-right\"><i class=\"qicon-calendar\"><\/i><\/span><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_5\"><div class=\"quform-element quform-element-textarea quform-element-1_13 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_13\"><label class=\"quform-label-text\" for=\"quform_1_13_98e039\">Address<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_13 quform-field-size-fat\"><div class=\"quform-input quform-input-textarea quform-input-1_13 quform-cf\"><textarea id=\"quform_1_13_98e039\" name=\"quform_1_13\" class=\"quform-field quform-field-textarea quform-field-1_13\" placeholder=\"Address\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_14 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_14\"><label class=\"quform-label-text\" for=\"quform_1_14_98e039\">Postcode<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_14 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_14 quform-cf\"><input type=\"text\" id=\"quform_1_14_98e039\" name=\"quform_1_14\" class=\"quform-field quform-field-text quform-field-1_14\" placeholder=\"Postcode\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-1_58 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_58\"><label class=\"quform-label-text\" id=\"quform_1_58_98e039_label\">Preferred Location<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_58 quform-field-size-fat\"><div class=\"quform-input quform-input-radio quform-input-1_58 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_58_98e039_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_1\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_1\" value=\"Farringdon\" \/><label for=\"quform_1_58_98e039_1\" class=\"quform-option-label quform-option-label-1_58_1\"><span class=\"quform-option-text\">Farringdon<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_8\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_8\" value=\"Barbican\" \/><label for=\"quform_1_58_98e039_8\" class=\"quform-option-label quform-option-label-1_58_8\"><span class=\"quform-option-text\">Barbican<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_9\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_9\" value=\"CanaryWharf\" \/><label for=\"quform_1_58_98e039_9\" class=\"quform-option-label quform-option-label-1_58_9\"><span class=\"quform-option-text\">Canary Wharf<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_2\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_2\" value=\"Holborn\" \/><label for=\"quform_1_58_98e039_2\" class=\"quform-option-label quform-option-label-1_58_2\"><span class=\"quform-option-text\">Holborn*<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_6\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_6\" value=\"Hampstead\" \/><label for=\"quform_1_58_98e039_6\" class=\"quform-option-label quform-option-label-1_58_6\"><span class=\"quform-option-text\">Hampstead*<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_5\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_5\" value=\"Redbridge\" \/><label for=\"quform_1_58_98e039_5\" class=\"quform-option-label quform-option-label-1_58_5\"><span class=\"quform-option-text\">Redbridge*<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_4\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_4\" value=\"Lancaster\" \/><label for=\"quform_1_58_98e039_4\" class=\"quform-option-label quform-option-label-1_58_4\"><span class=\"quform-option-text\">Lancaster*<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_58\" id=\"quform_1_58_98e039_7\" class=\"quform-field quform-field-radio quform-field-1_58 quform-field-1_58_7\" value=\"Manchester\" \/><label for=\"quform_1_58_98e039_7\" class=\"quform-option-label quform-option-label-1_58_7\"><span class=\"quform-option-text\">Manchester<\/span><\/label><\/div><\/div><\/div><p class=\"quform-description quform-description-below\">*Orthodontic referrals only<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_37 quform-cf\"><div class=\"quform-spacer\"><h3>Dental Insurance Cover<\/h3><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_44 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_45\"><div class=\"quform-element quform-element-radio quform-element-1_54 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_54\"><label class=\"quform-label-text\" id=\"quform_1_54_98e039_label\">Dental Insurance Cover<\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-1_54 quform-field-size-fat\"><div class=\"quform-input quform-input-radio quform-input-1_54 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_1_54_98e039_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_54\" id=\"quform_1_54_98e039_1\" class=\"quform-field quform-field-radio quform-field-1_54 quform-field-1_54_1\" value=\"Yes\" \/><label for=\"quform_1_54_98e039_1\" class=\"quform-option-label quform-option-label-1_54_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_1_54\" id=\"quform_1_54_98e039_2\" class=\"quform-field quform-field-radio quform-field-1_54 quform-field-1_54_2\" value=\"No\" \/><label for=\"quform_1_54_98e039_2\" class=\"quform-option-label quform-option-label-1_54_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_55 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_55\"><label class=\"quform-label-text\" for=\"quform_1_55_98e039\">Name of Insurance Company<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_55 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_55 quform-cf\"><input type=\"text\" id=\"quform_1_55_98e039\" name=\"quform_1_55\" class=\"quform-field quform-field-text quform-field-1_55\" placeholder=\"Name of Insurance Company\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_51\"><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_56 quform-cf\"><div class=\"quform-spacer\"><h2>Reason for Referral<\/h2><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_16 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_16\"><label class=\"quform-label-text\" for=\"quform_1_16_98e039\">Reason for Referral<\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-1_16 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_16 quform-cf\"><input type=\"text\" id=\"quform_1_16_98e039\" name=\"quform_1_16\" class=\"quform-field quform-field-text quform-field-1_16\" placeholder=\"Enter details...\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_17 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_18\"><div class=\"quform-element quform-element-html quform-element-1_23 quform-cf\"><div class=\"quform-spacer\"><h2>Treatment<\/h2><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-1_20 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_20\"><label class=\"quform-label-text\" id=\"quform_1_20_98e039_label\">Treatment<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-1_20 quform-field-size-fat\"><div class=\"quform-input quform-input-checkbox quform-input-1_20 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_1_20_98e039_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_3\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_3\" value=\"Dental Implants\" \/><label for=\"quform_1_20_98e039_3\" class=\"quform-option-label quform-option-label-1_20_3\"><span class=\"quform-option-text\">Dental Implants<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_8\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_8\" value=\"Orthodontics\" \/><label for=\"quform_1_20_98e039_8\" class=\"quform-option-label quform-option-label-1_20_8\"><span class=\"quform-option-text\">Orthodontics<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_6\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_6\" value=\"Restorative Dentistry\" \/><label for=\"quform_1_20_98e039_6\" class=\"quform-option-label quform-option-label-1_20_6\"><span class=\"quform-option-text\">Restorative Dentistry<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_7\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_7\" value=\"Sinus \/ Block Grafting\" \/><label for=\"quform_1_20_98e039_7\" class=\"quform-option-label quform-option-label-1_20_7\"><span class=\"quform-option-text\">Sinus \/ Block Grafting<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_10\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_10\" value=\"Endodontics\" \/><label for=\"quform_1_20_98e039_10\" class=\"quform-option-label quform-option-label-1_20_10\"><span class=\"quform-option-text\">Endodontics<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_9\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_9\" value=\"Sedation\" \/><label for=\"quform_1_20_98e039_9\" class=\"quform-option-label quform-option-label-1_20_9\"><span class=\"quform-option-text\">Sedation<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_11\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_11\" value=\"Periodontics \" \/><label for=\"quform_1_20_98e039_11\" class=\"quform-option-label quform-option-label-1_20_11\"><span class=\"quform-option-text\">Periodontics <\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_1_20[]\" id=\"quform_1_20_98e039_12\" class=\"quform-field quform-field-checkbox quform-field-1_20 quform-field-1_20_12\" value=\"Oral Surgery\" \/><label for=\"quform_1_20_98e039_12\" class=\"quform-option-label quform-option-label-1_20_12\"><span class=\"quform-option-text\">Oral Surgery<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_19\"><div class=\"quform-element quform-element-html quform-element-1_21 quform-cf\"><div class=\"quform-spacer\"><h2>Image Upload<\/h2><\/div><\/div><div class=\"quform-element quform-element-file quform-element-1_22 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_22\"><label class=\"quform-label-text\" for=\"quform_1_22_98e039\">Image Upload<\/label><\/div><div class=\"quform-inner quform-inner-file quform-inner-1_22 quform-field-size-fat\"><div class=\"quform-input quform-input-file quform-input-1_22 quform-cf quform-button-size-huge\"><input type=\"file\" id=\"quform_1_22_98e039\" name=\"quform_1_22[]\" class=\"quform-field quform-field-file quform-field-1_22 quform-field-file-enhanced\" multiple data-config=\"{&quot;id&quot;:22,&quot;identifier&quot;:&quot;1_22&quot;,&quot;name&quot;:&quot;quform_1_22&quot;,&quot;max&quot;:5,&quot;size&quot;:10485760,&quot;allowedExtensions&quot;:[&quot;jpg&quot;,&quot;jpeg&quot;,&quot;png&quot;,&quot;gif&quot;,&quot;pdf&quot;],&quot;notAllowedTypeWithFilename&quot;:&quot;File type of &#039;%filename%&#039; is not allowed&quot;,&quot;tooBigWithFilename&quot;:&quot;File &#039;%filename%&#039; exceeds the maximum allowed file size&quot;,&quot;tooMany&quot;:&quot;You cannot upload more than %max% file(s)&quot;,&quot;buttonType&quot;:&quot;dropzone&quot;,&quot;buttonText&quot;:&quot;Browse...&quot;,&quot;buttonIcon&quot;:&quot;qicon-file_upload&quot;,&quot;buttonIconPosition&quot;:&quot;right&quot;}\" \/><\/div><p class=\"quform-description quform-description-below\">Upload any relevant photos or radiographs.<br \/>Accepted file types are jpg, gif, png or pdf.<br \/>Up to 5 files, max file size 10Mb.<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_24 quform-cf\"><div class=\"quform-spacer\"><h2>Relevant Medical \/ Dental History<\/h2><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-1_25 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-1_25\"><label class=\"quform-label-text\" for=\"quform_1_25_98e039\">Relevant Medical \/ Dental History<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-1_25 quform-field-size-fat\"><div class=\"quform-input quform-input-textarea quform-input-1_25 quform-cf\"><textarea id=\"quform_1_25_98e039\" name=\"quform_1_25\" class=\"quform-field quform-field-textarea quform-field-1_25\" placeholder=\"Please give details of any medical conditions and medication.\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-1_26 quform-cf\"><div class=\"quform-spacer\"><h2>Referring Dentist Details<\/h2><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-1_27 quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-1_28\"><div class=\"quform-element quform-element-text quform-element-1_29 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-1_29 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_29 quform-cf\"><input type=\"text\" id=\"quform_1_29_98e039\" name=\"quform_1_29\" class=\"quform-field quform-field-text quform-field-1_29\" placeholder=\"Name\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-1_31 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-email quform-inner-1_31 quform-field-size-fat\"><div class=\"quform-input quform-input-email quform-input-1_31 quform-cf\"><input type=\"email\" id=\"quform_1_31_98e039\" name=\"quform_1_31\" class=\"quform-field quform-field-email quform-field-1_31\" placeholder=\"Email address\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_32 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-1_32 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_32 quform-cf\"><input type=\"text\" id=\"quform_1_32_98e039\" name=\"quform_1_32\" class=\"quform-field quform-field-text quform-field-1_32\" placeholder=\"Telephone Number\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-1_34\"><div class=\"quform-element quform-element-textarea quform-element-1_35 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-textarea quform-inner-1_35 quform-field-size-fat\"><div class=\"quform-input quform-input-textarea quform-input-1_35 quform-cf\"><textarea id=\"quform_1_35_98e039\" name=\"quform_1_35\" class=\"quform-field quform-field-textarea quform-field-1_35\" placeholder=\"Address\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-1_36 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-1_36 quform-field-size-fat\"><div class=\"quform-input quform-input-text quform-input-1_36 quform-cf\"><input type=\"text\" id=\"quform_1_36_98e039\" name=\"quform_1_36\" class=\"quform-field quform-field-text quform-field-1_36\" placeholder=\"Postcode\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-1_2 quform-cf quform-button-size-huge\"><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-1_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Submit Form<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-tree\"><label for=\"quform_1_0_98e039\">This field should be left blank<\/label><input type=\"text\" id=\"quform_1_0_98e039\" name=\"quform_1_0\" class=\"quform-field quform-field-tree quform-field-1_0\" tabindex=\"-1\" autocomplete=\"off\" \/><\/div><\/div><\/div><\/div><div class=\"quform-upload-progress-wrap\"><div class=\"quform-upload-progress-bar-wrap\"><div class=\"quform-upload-progress-bar\"><\/div><\/div><div class=\"quform-upload-info quform-cf\"><div class=\"quform-upload-filename\"><\/div><\/div><\/div><\/div><\/form><\/div>[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Our Referral Service We welcome dentist referrals for Dental Implants, Sedation, Orthodontics, Restorative Dentistry, Endodontics, Periodontics and oral surgery. We hope you will be happy with the service we provide and the knowledge that your patients will always be returned to your care. Simply fill in the form below,or\u00a0download and complete a pdf version. For [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":575,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"_acf_changed":false,"_et_pb_use_builder":"on","_et_pb_old_content":"<!-- wp:paragraph -->\r\n<p>This is an example page. It's different from a blog post because it will stay in one place and will show up in your site navigation (in most themes). Most people start with an About page that introduces them to potential site visitors. It might say something like this:<\/p>\r\n<!-- \/wp:paragraph --><!-- wp:quote -->\r\n<blockquote class=\"wp-block-quote\">\r\n<p>Hi there! I'm a bike messenger by day, aspiring actor by night, and this is my website. I live in Los Angeles, have a great dog named Jack, and I like pi\u00f1a coladas. (And gettin' caught in the rain.)<\/p>\r\n<\/blockquote>\r\n<!-- \/wp:quote --><!-- wp:paragraph -->\r\n<p>...or something like this:<\/p>\r\n<!-- \/wp:paragraph --><!-- wp:quote -->\r\n<blockquote class=\"wp-block-quote\">\r\n<p>The XYZ Doohickey Company was founded in 1971, and has been providing quality doohickeys to the public ever since. Located in Gotham City, XYZ employs over 2,000 people and does all kinds of awesome things for the Gotham community.<\/p>\r\n<\/blockquote>\r\n<!-- \/wp:quote --><!-- wp:paragraph -->\r\n<p>As a new WordPress user, you should go to <a href=\"https:\/\/malmin.co.uk\/wp-admin\/\">your dashboard<\/a> to delete this page and create new pages for your content. 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