﻿{"id":6198,"date":"2023-06-26T08:45:36","date_gmt":"2023-06-26T08:45:36","guid":{"rendered":"https:\/\/ruhdental.com\/legacy\/?page_id=6198"},"modified":"2023-10-06T07:02:39","modified_gmt":"2023-10-06T07:02:39","slug":"refer-patient","status":"publish","type":"page","link":"https:\/\/ruhdental.com\/legacy\/refer-patient\/","title":{"rendered":"Refer Patient"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row full_width=&#8221;stretch_row&#8221; css=&#8221;.vc_custom_1687768980195{background: #161515 url(https:\/\/ruhdental.com\/legacy\/wp-content\/uploads\/2023\/06\/Background-Banner.webp?id=6199) !important;}&#8221; el_class=&#8221;gm-banner&#8221;][vc_column][vc_custom_heading text=&#8221;Let our experts help you&#8221; 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font_container=&#8221;tag:p|font_size:24|text_align:center|color:%23ffffff&#8221;][\/vc_column_inner][vc_column_inner el_class=&#8221;column-three&#8221; width=&#8221;1\/3&#8243;][vc_single_image image=&#8221;6205&#8243; img_size=&#8221;full&#8221; alignment=&#8221;center&#8221;][vc_custom_heading text=&#8221;Refer patient back to you for ongoing care&#8221; font_container=&#8221;tag:p|font_size:24|text_align:center|color:%23ffffff&#8221;][\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row][vc_row el_class=&#8221;gm-refer-form-section&#8221; css=&#8221;.vc_custom_1687488949423{background-color: #ffffff !important;}&#8221;][vc_column 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class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"6214\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/legacy\/wp-json\/wp\/v2\/pages\/6198\" data-token=\"a9412c0e0c2366c0288089bd2f0435ce\" data-token-time=\"1781013021\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-6214-field_9-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"9\"><label class=\"wpforms-field-label wpforms-label-hide\">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-6214-field_9\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][9][first]\" placeholder=\"Patient First Name\" required><label for=\"wpforms-6214-field_9\" 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data-field-id=\"3\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-6214-field_3\">Patient Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-6214-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" placeholder=\"Patient Email\" spellcheck=\"false\" required><\/div><div id=\"wpforms-6214-field_4-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"4\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-6214-field_4\">Preferred Clinic <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-6214-field_4\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][4]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Preferred Clinic<\/option><option value=\"Fleet Street\"  class=\"choice-1 depth-1\"  >Fleet Street<\/option><option value=\"Notting Hill Gate\"  class=\"choice-2 depth-1\"  >Notting Hill Gate<\/option><option value=\"Manchester\"  class=\"choice-3 depth-1\"  >Manchester<\/option><\/select><\/div><div id=\"wpforms-6214-field_2-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"2\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-6214-field_2\">Patients Main Concern <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6214-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" placeholder=\"Patients Main Concern\" required><\/div><div id=\"wpforms-6214-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-6214-field_6\">What You Need Help With <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6214-field_6\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][6]\" placeholder=\"What You Need Help With\" required><\/div><div id=\"wpforms-6214-field_7-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"7\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-6214-field_7\">Your Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6214-field_7\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][7]\" placeholder=\"Your Name\" required><\/div><div id=\"wpforms-6214-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-6214-field_8\">Name of Your Clinic <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6214-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" placeholder=\"Name of Your Clinic\" 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