{"id":300,"date":"2018-03-27T13:06:37","date_gmt":"2018-03-27T17:06:37","guid":{"rendered":"https:\/\/maxillomauricie.com\/referer-un-patient\/"},"modified":"2024-05-02T16:12:25","modified_gmt":"2024-05-02T20:12:25","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/maxillomauricie.com\/en\/health-specialists\/refer-a-patient\/","title":{"rendered":"Refer a patient"},"content":{"rendered":"<section class=\"l-section wpb_row us_custom_48e2d10b height_huge parallax_ver\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-separator size_custom\" style=\"height:300px\"><\/div><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row height_huge\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"g-cols wpb_row via_flex valign_top type_default stacking_default\"><div class=\"vc_col-sm-2 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-separator size_custom\" style=\"height:32px\"><\/div><\/div><\/div><\/div><div class=\"vc_col-sm-8 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><h1 style=\"text-align: center;\">REFER A PATIENT<\/h1>\n<\/div><\/div><div class=\"w-separator size_small with_line width_30 thick_1 style_solid color_border align_center\"><div class=\"w-separator-h\"><\/div><\/div><div class=\"wpb_text_column\"><div class=\"wpb_wrapper\"><div data-uniq='685f8e87e2d7e' class='uniq-685f8e87e2d7e formcraft-css form-live align-left'><style type='text\/css' scoped='scoped'>.powered-by {\ndisplay: none !important;\n}<\/style><script> window.formcraftLogic = window.formcraftLogic || {}; window.formcraftLogic[7] = [[[[\"field76\",\"equal_to\",\"Infant frenotomy\"]],[[\"show_fields\",\"field17,field20,field19,field18,field24,field25,field28\"]],\"and\"],[[[\"field76\",\"equal_to\",\"TMJ\"]],[[\"show_fields\",\"field29,field30,field31,field32,field33,field34,field35,field37,field39,field40,field41,field42,field44,field45,field46,field47,field48,field49,field50,field51,field77\"]],\"and\"],[[[\"field76\",\"equal_to\",\"Pathology\"]],[[\"show_fields\",\"field9\"]],\"and\"],[[[\"field9\",\"contains\",\"Suspicion of dysplasia\\\/carcinoma\"]],[[\"show_fields\",\"field52,field56,field57,field58,field59,field60\"]],\"and\"],[[[\"field60\",\"equal_to\",\"Yes\"],[\"field9\",\"contains\",\"Suspicion of dysplasia\\\/carcinoma\"]],[[\"show_fields\",\"field61\"]],\"and\"],[[[\"field9\",\"contains\",\"Lichen 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gingivitis\"]],[[\"show_fields\",\"field71\"],[\"hide_fields\",\"field14,field11,field12,field6\"]],\"and\"],[[[\"field9\",\"contains\",\"Other\"]],[[\"show_fields\",\"field72,field73,field74,field53\"]],\"and\"],[[[\"field74\",\"equal_to\",\"Yes\"],[\"field9\",\"contains\",\"Other\"]],[[\"show_fields\",\"field75\"]],\"and\"]]; <\/script><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination width-100\">\n\t\t\t\t\t<!-- ngRepeat: page in Builder.FormElements track by $index --><div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div><!-- end ngRepeat: page in Builder.FormElements track by $index -->\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-7 .fc-pagination-cover 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.prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #e4c2a7;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c8aa92;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-7.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form .final-success .final-success-check {\n\t\t\t\tborder: 2px solid #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover .time-fields-cover,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover .awesomplete ul\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"radio\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"checkbox\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #ffffff;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"radio\"]:checked,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"checkbox\"]:checked {\n\t\t\t\tborder-color: #c8aa92;\n\t\t\t\tbackground: #e4c2a7;\t\t\t\t\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c8aa92;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c8aa92 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .fileupload-cover .button-file\n\t\t\t{\n\t\t\t\tborder-color: #c8aa92;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #e4c2a7;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: none;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-auto-scroll=\"\" data-no-message-redirect=\"\" data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"7\" class=\"fc-form fc-form-7 align- fc-temp-class save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-placeholder field-border-visible frame-hidden field-alignment-left  \" style=\"width: 99%; color: #666666; font-size: 100%; background: none\">\n\t\t\t\t<!-- ngRepeat: page in Builder.FormElements track by $index --><div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content      ng-not-empty\">\n\t\t\t\t\t\t<div data-identifier=\"field1\" data-index=\"0\" style=\"width: 50%\" class=\" form-element form-element-field1 options-false form-element-0 default-false form-element-type-oneLineText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Refering dentist\/physician name<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Refering dentist\/physician name\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field7\" data-index=\"1\" style=\"width: 50%\" class=\" even form-element form-element-field7 options-false form-element-1 default-false form-element-type-oneLineText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Patient name<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Patient name\" make-read-only=\"false\" data-field-id=\"field7\" name=\"field7[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field15\" data-index=\"2\" style=\"width: 50%\" class=\" form-element form-element-field15 options-false form-element-2 default-false form-element-type-email is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"email-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Refering dentist\/physician email<\/span><\/span><span class=\"sub-label\"><span >a valid email<\/span><\/span><\/span><div><span class=\"error\"><\/span><input placeholder=\"Refering dentist\/physician email\" data-field-id=\"field15\" type=\"text\" data-val-type=\"email\" make-read-only=\"\" data-is-required=\"true\" name=\"field15\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">email<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field8\" data-index=\"3\" style=\"width: 50%\" class=\" even form-element form-element-field8 options-false form-element-3 default-false form-element-type-oneLineText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Patient telephone number<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Patient telephone number\" make-read-only=\"false\" data-field-id=\"field8\" name=\"field8[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field16\" data-index=\"4\" style=\"width: 100%\" class=\" form-element form-element-field16 options-false form-element-4 default-false form-element-type-datepicker is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"datepicker-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Birth date<\/span><\/span><span class=\"sub-label\"><span >Birth date<\/span><\/span><\/span><div><span class=\"error\"><\/span><input autocomplete=\"off\" data-field-id=\"field16\" placeholder=\"Birth date\" type=\"text\" class=\"validation-lenient    hasDatepicker ng-empty\" data-is-required=\"false\" datepicker=\"\" data-date-min-range=\"\" data-date-format=\"dd\/mm\/yy\" data-date-days=\"{&quot;0&quot;:true,&quot;1&quot;:true,&quot;2&quot;:true,&quot;3&quot;:true,&quot;4&quot;:true,&quot;5&quot;:true,&quot;6&quot;:true}\" data-date-min=\"\" data-date-min-alt=\"\" data-date-max-alt=\"\" data-date-max=\"\" data-date-lang=\"en\" name=\"field16\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\"><i class=\"formcraft-icon\">date_range<\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field13\" data-index=\"5\" style=\"width: 100%\" class=\" even form-element form-element-field13 options-false form-element-5 default-false form-element-type-fileupload is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"wide- fileupload-cover field-cover\"><span class=\"sub-label-\"><span class=\"main-label\"><span >Upload your X-rays<\/span><\/span><span class=\"sub-label\"><span >upload<\/span><\/span><\/span><div><span class=\"error\"><\/span><div class=\"button button-file fileupload-button\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><i class=\"icon-upload-cloud formcraft-icon\">cloud_upload<\/i><span >Upload your X-rays<\/span><input type=\"file\" data-name-list=\"field13\" name=\"files\" multiple=\"multiple\" data-allow-extensions=\"\" data-min-files=\"\" data-max-files=\"\" data-max-size=\"\"><\/div><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field76\" data-index=\"6\" style=\"width: 100%\" class=\" form-element form-element-field76 options-false form-element-6 default-false form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Consultation reason<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Extraction\" class=\"validation-lenient\"><span><span >Extraction<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Wisdom teeth\" class=\"validation-lenient\"><span><span >Wisdom teeth<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Pre-prosthetic surgery\" class=\"validation-lenient\"><span><span >Pre-prosthetic surgery<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Implantology\" class=\"validation-lenient\"><span><span >Implantology<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Bone graft\" class=\"validation-lenient\"><span><span >Bone graft<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Laser\" class=\"validation-lenient\"><span><span >Laser<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Impacted tooth exposition and traction\" class=\"validation-lenient\"><span><span >Impacted tooth exposition and traction<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Orthognathic surgery\" class=\"validation-lenient\"><span><span >Orthognathic surgery<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"TMJ\" class=\"validation-lenient\"><span><span >TMJ<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Pathology\" class=\"validation-lenient\"><span><span >Pathology<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Fracture\" class=\"validation-lenient\"><span><span >Fracture<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Infant frenotomy\" class=\"validation-lenient\"><span><span >Infant frenotomy<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"Scan\" class=\"validation-lenient\"><span><span >Scan<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field76\" type=\"checkbox\" data-is-required=\"false\" name=\"field76[]\" value=\"TADS\" class=\"validation-lenient\"><span><span >TADS<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field9\" data-index=\"7\" style=\"width: 100%\" class=\" even form-element form-element-field9 options-false form-element-7 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Reason for referral<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field9\" type=\"radio\" data-is-required=\"false\" name=\"field9[]\" value=\"Suspicion of dysplasia\/carcinoma\" class=\"validation-lenient\"><span><span >Suspicion of dysplasia\/carcinoma<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field9\" type=\"radio\" data-is-required=\"false\" name=\"field9[]\" value=\"Lichen planus\" class=\"validation-lenient\"><span><span >Lichen planus<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field9\" type=\"radio\" data-is-required=\"false\" name=\"field9[]\" value=\"Vesiculobullous disease\/desquamative gingivitis\" class=\"validation-lenient\"><span><span >Vesiculobullous disease\/desquamative gingivitis<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field9\" type=\"radio\" data-is-required=\"false\" name=\"field9[]\" value=\"Other\" class=\"validation-lenient\"><span><span >Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field29\" data-index=\"8\" style=\"width: 100%\" class=\" form-element form-element-field29 options-false form-element-8 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >What is your specialty ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field29\" type=\"radio\" data-is-required=\"false\" name=\"field29[]\" value=\"Dentist\" class=\"validation-lenient\"><span><span >Dentist<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field29\" type=\"radio\" data-is-required=\"false\" name=\"field29[]\" value=\"Family Doctor\" class=\"validation-lenient\"><span><span >Family Doctor<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field29\" type=\"radio\" data-is-required=\"false\" name=\"field29[]\" value=\"Physiotherapist\" class=\"validation-lenient\"><span><span >Physiotherapist<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field29\" type=\"radio\" data-is-required=\"false\" name=\"field29[]\" value=\"Other\" class=\"validation-lenient\"><span><span >Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field30\" data-index=\"9\" style=\"width: 100%\" class=\" even form-element form-element-field30 options-false form-element-9 default-true form-element-type-oneLineText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Reason for the consultation<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Reason for the consultation\" make-read-only=\"false\" data-field-id=\"field30\" name=\"field30[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field31\" data-index=\"10\" style=\"width: 100%\" class=\" form-element form-element-field31 options-false form-element-10 default-true form-element-type-oneLineText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Main complaint<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Main complaint\" make-read-only=\"false\" data-field-id=\"field31\" name=\"field31[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"false\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field32\" data-index=\"11\" style=\"width: 100%\" class=\" even form-element form-element-field32 options-false form-element-11 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Is the patient currently in pain ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field32\" type=\"radio\" data-is-required=\"false\" name=\"field32[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field32\" type=\"radio\" data-is-required=\"false\" name=\"field32[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field33\" data-index=\"12\" style=\"width: 100%\" class=\" form-element form-element-field33 options-false form-element-12 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Does the patient frequently experience headaches ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field33\" type=\"radio\" data-is-required=\"false\" name=\"field33[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field33\" type=\"radio\" data-is-required=\"false\" name=\"field33[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field34\" data-index=\"13\" style=\"width: 100%\" class=\" even form-element form-element-field34 options-false form-element-13 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Has the patient ever had a jaw or facial trauma ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"radio\" data-is-required=\"false\" name=\"field34[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field34\" type=\"radio\" data-is-required=\"false\" name=\"field34[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field35\" data-index=\"14\" style=\"width: 100%\" class=\" form-element form-element-field35 options-false form-element-14 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Does the patient feel a limitation in their mouth opening ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field35\" type=\"radio\" data-is-required=\"false\" name=\"field35[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field35\" type=\"radio\" data-is-required=\"false\" name=\"field35[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field77\" data-index=\"15\" style=\"width: 100%\" class=\" even form-element form-element-field77 options-false form-element-15 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images-true checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Does the patient exhibit a parafunction?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field77\" type=\"radio\" data-is-required=\"false\" name=\"field77[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field77\" type=\"radio\" data-is-required=\"false\" name=\"field77[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field49\" data-index=\"16\" style=\"width: 100%\" class=\" form-element form-element-field49 options-false form-element-16 default-true form-element-type-customText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><h2 >Medication tried<\/h2><\/div><input type=\"hidden\" name=\"field49\" data-field-id=\"field49\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field37\" data-index=\"17\" style=\"width: 100%\" class=\" even form-element form-element-field37 options-false form-element-17 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >How many different medications has the patient tried ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field37\" type=\"radio\" data-is-required=\"false\" name=\"field37[]\" value=\"0\" class=\"validation-lenient\"><span><span >0<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field37\" type=\"radio\" data-is-required=\"false\" name=\"field37[]\" value=\"1\" class=\"validation-lenient\"><span><span >1<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field37\" type=\"radio\" data-is-required=\"false\" name=\"field37[]\" value=\"2\" class=\"validation-lenient\"><span><span >2<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field37\" type=\"radio\" data-is-required=\"false\" name=\"field37[]\" value=\"3\" class=\"validation-lenient\"><span><span >3<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field37\" type=\"radio\" data-is-required=\"false\" name=\"field37[]\" value=\"4\" class=\"validation-lenient\"><span><span >4<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field50\" data-index=\"18\" style=\"width: 100%\" class=\" form-element form-element-field50 options-false form-element-18 default-true form-element-type-customText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><h2 >Previous dental treatments<\/h2><\/div><input type=\"hidden\" name=\"field50\" data-field-id=\"field50\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field39\" data-index=\"19\" style=\"width: 100%\" class=\" even form-element form-element-field39 options-false form-element-19 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Occlusal splint<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field39\" type=\"radio\" data-is-required=\"false\" name=\"field39[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field39\" type=\"radio\" data-is-required=\"false\" name=\"field39[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field40\" data-index=\"20\" style=\"width: 100%\" class=\" form-element form-element-field40 options-false form-element-20 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Occlusal adjustment<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field40\" type=\"radio\" data-is-required=\"false\" name=\"field40[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field40\" type=\"radio\" data-is-required=\"false\" name=\"field40[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field41\" data-index=\"21\" style=\"width: 100%\" class=\" even form-element form-element-field41 options-false form-element-21 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Oral medicine consultation<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field41\" type=\"radio\" data-is-required=\"false\" name=\"field41[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field41\" type=\"radio\" data-is-required=\"false\" name=\"field41[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field42\" data-index=\"22\" style=\"width: 100%\" class=\" form-element form-element-field42 options-false form-element-22 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Orthodontic treatment<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"radio\" data-is-required=\"false\" name=\"field42[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field42\" type=\"radio\" data-is-required=\"false\" name=\"field42[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field51\" data-index=\"23\" style=\"width: 100%\" class=\" even form-element form-element-field51 options-false form-element-23 default-true form-element-type-customText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><h2 >Previous biomechanical treatments<\/h2><\/div><input type=\"hidden\" name=\"field51\" data-field-id=\"field51\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field44\" data-index=\"24\" style=\"width: 100%\" class=\" form-element form-element-field44 options-false form-element-24 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Physiotherapy<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field44\" type=\"radio\" data-is-required=\"false\" name=\"field44[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field44\" type=\"radio\" data-is-required=\"false\" name=\"field44[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field45\" data-index=\"25\" style=\"width: 100%\" class=\" even form-element form-element-field45 options-false form-element-25 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Chiropractic<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field45\" type=\"radio\" data-is-required=\"false\" name=\"field45[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field45\" type=\"radio\" data-is-required=\"false\" name=\"field45[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field46\" data-index=\"26\" style=\"width: 100%\" class=\" form-element form-element-field46 options-false form-element-26 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Massage therapy<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field46\" type=\"radio\" data-is-required=\"false\" name=\"field46[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field46\" type=\"radio\" data-is-required=\"false\" name=\"field46[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field47\" data-index=\"27\" style=\"width: 100%\" class=\" even form-element form-element-field47 options-false form-element-27 default-true form-element-type-checkbox is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Osteopathy<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field47\" type=\"radio\" data-is-required=\"false\" name=\"field47[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field47\" type=\"radio\" data-is-required=\"false\" name=\"field47[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field48\" data-index=\"28\" style=\"width: 100%\" class=\" form-element form-element-field48 options-false form-element-28 default-true form-element-type-checkbox is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Acupuncture<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field48\" type=\"radio\" data-is-required=\"false\" name=\"field48[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field48\" type=\"radio\" data-is-required=\"false\" name=\"field48[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field24\" data-index=\"29\" style=\"width: 100%\" class=\" even form-element form-element-field24 options-false form-element-29 default-true form-element-type-textarea is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"textarea-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >What is the indication for frenotomy according to your assessment?<\/span><\/span><span class=\"sub-label\"><span >plus de d\u00e9tails<\/span><\/span><\/span><div><span class=\"error\"><\/span><textarea data-field-id=\"field24\" placeholder=\"What is the indication for frenotomy according to your assessment?\" class=\"validation-lenient\" name=\"field24\" value=\"\" rows=\"5\" data-min-char=\"\" data-max-char=\"\" data-is-required=\"true\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\" style=\"min-height: 110.781px\"><\/textarea><div class=\"count-false\"><span class=\"current-count\">0<\/span> \/ <span class=\"max-count \"><\/span><\/div><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field25\" data-index=\"30\" style=\"width: 100%\" class=\" form-element form-element-field25 options-false form-element-30 default-true form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Have the patient and parent met with a breastfeeding consultant?<\/span><\/span><span class=\"sub-label\"><span >Such a consultation is required before proceeding with a frenotomy.<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"radio\" data-is-required=\"true\" name=\"field25[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field25\" type=\"radio\" data-is-required=\"true\" name=\"field25[]\" value=\" No\" class=\"validation-lenient\"><span><span > No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field17\" data-index=\"31\" style=\"width: 100%\" class=\" even form-element form-element-field17 options-false form-element-31 default-true form-element-type-checkbox is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images-true checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >What does the tongue-tip look like ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/dos-apex-0.jpg\"><input data-field-id=\"field17\" type=\"radio\" data-is-required=\"true\" name=\"field17[]\" value=\"0\" class=\"validation-lenient\"><span><span >0<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/dos-apex-1.jpg\"><input data-field-id=\"field17\" type=\"radio\" data-is-required=\"true\" name=\"field17[]\" value=\"1\" class=\"validation-lenient\"><span><span >1<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/dos-apex-2.jpg\"><input data-field-id=\"field17\" type=\"radio\" data-is-required=\"true\" name=\"field17[]\" value=\"2\" class=\"validation-lenient\"><span><span >2<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field20\" data-index=\"32\" style=\"width: 100%\" class=\" form-element form-element-field20 options-false form-element-32 default-true form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images-true checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Where is it fixed to the gum ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/gencive-plancher-0.jpg\"><input data-field-id=\"field20\" type=\"radio\" data-is-required=\"true\" name=\"field20[]\" value=\"0\" class=\"validation-lenient\"><span><span >0<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/gencive-plancher-1.jpg\"><input data-field-id=\"field20\" type=\"radio\" data-is-required=\"true\" name=\"field20[]\" value=\"1\" class=\"validation-lenient\"><span><span >1<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/gencive-plancher-2.jpg\"><input data-field-id=\"field20\" type=\"radio\" data-is-required=\"true\" name=\"field20[]\" value=\"2\" class=\"validation-lenient\"><span><span >2<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field19\" data-index=\"33\" style=\"width: 100%\" class=\" even form-element form-element-field19 options-false form-element-33 default-true form-element-type-checkbox is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images-true checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >How high can it lift (wide open mouth) ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/hauteur-0.jpg\"><input data-field-id=\"field19\" type=\"radio\" data-is-required=\"true\" name=\"field19[]\" value=\"0\" class=\"validation-lenient\"><span><span >0<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/hauteur-1.jpg\"><input data-field-id=\"field19\" type=\"radio\" data-is-required=\"true\" name=\"field19[]\" value=\"1\" class=\"validation-lenient\"><span><span >1<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/hauteur-2.jpg\"><input data-field-id=\"field19\" type=\"radio\" data-is-required=\"true\" name=\"field19[]\" value=\"2\" class=\"validation-lenient\"><span><span >2<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field18\" data-index=\"34\" style=\"width: 100%\" class=\" form-element form-element-field18 options-false form-element-34 default-true form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images-true checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >How far can it stick out ?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/sortir-bouche-0.jpg\"><input data-field-id=\"field18\" type=\"radio\" data-is-required=\"true\" name=\"field18[]\" value=\"0\" class=\"validation-lenient\"><span><span >0<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/sortir-bouche-1.jpg\"><input data-field-id=\"field18\" type=\"radio\" data-is-required=\"true\" name=\"field18[]\" value=\"1\" class=\"validation-lenient\"><span><span >1<\/span><\/span><\/label><label style=\"width:\" ><img decoding=\"async\" alt=\"\" src=\"https:\/\/maxillomauricie.com\/wp-content\/uploads\/2024\/10\/sortir-bouche-2.jpg\"><input data-field-id=\"field18\" type=\"radio\" data-is-required=\"true\" name=\"field18[]\" value=\"2\" class=\"validation-lenient\"><span><span >2<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field27\" data-index=\"35\" style=\"width: 100%\" class=\" even form-element form-element-field27 options-false form-element-35 default-true form-element-type-checkbox is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Have the patient and parent met with a breastfeeding consultant?<\/span><\/span><span class=\"sub-label\"><span >Such a consultation is required before proceeding with a frenotomy.<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field27\" type=\"radio\" data-is-required=\"true\" name=\"field27[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field27\" type=\"radio\" data-is-required=\"true\" name=\"field27[]\" value=\" No\" class=\"validation-lenient\"><span><span > No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field28\" data-index=\"36\" style=\"width: 100%\" class=\" form-element form-element-field28 options-false form-element-36 default-true form-element-type-checkbox is-required-true odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >What is the patient's TABBY score?<\/span><\/span><span class=\"sub-label\"><span >Here's how to interpret the score:  8 and above = normal score; 6 to 7: limit score; 5 and below : possible tongue dysfunction<\/span><br ><span >We will only meet patients with a score of 5 and below.<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field28\" type=\"radio\" data-is-required=\"true\" name=\"field28[]\" value=\"8 and above\" class=\"validation-lenient\"><span><span >8 and above<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field28\" type=\"radio\" data-is-required=\"true\" name=\"field28[]\" value=\"6 to 7\" class=\"validation-lenient\"><span><span >6 to 7<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field28\" type=\"radio\" data-is-required=\"true\" name=\"field28[]\" value=\" 5 and below\" class=\"validation-lenient\"><span><span > 5 and below<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field52\" data-index=\"37\" style=\"width: 100%\" class=\" even form-element form-element-field52 options-false form-element-37 default-true form-element-type-customText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><h2 >Suspicion of Dysplasia \/ Carcinoma<\/h2><\/div><input type=\"hidden\" name=\"field52\" data-field-id=\"field52\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field56\" data-index=\"38\" style=\"width: 100%\" class=\" form-element form-element-field56 form-element-38 default-true form-element-type-checkbox odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >White lesion appearance<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"Induration\" class=\"validation-lenient\"><span><span >Induration<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"Ulceration\" class=\"validation-lenient\"><span><span >Ulceration<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"Leukoplakia\" class=\"validation-lenient\"><span><span >Leukoplakia<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field56\" type=\"checkbox\" data-is-required=\"true\" name=\"field56[]\" value=\"Erythroplakia\" class=\"validation-lenient\"><span><span >Erythroplakia<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field57\" data-index=\"39\" style=\"width: 100%\" class=\" even form-element form-element-field57 form-element-39 default-true form-element-type-oneLineText -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Region in the mouth<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Region in the mouth\" make-read-only=\"false\" data-field-id=\"field57\" name=\"field57[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field58\" data-index=\"40\" style=\"width: 100%\" class=\" form-element form-element-field58 form-element-40 default-true form-element-type-oneLineText odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Date of onset<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Date of onset\" make-read-only=\"false\" data-field-id=\"field58\" name=\"field58[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field59\" data-index=\"41\" style=\"width: 100%; position: relative; z-index: 999; left: 0px; top: 0px\" class=\" even form-element form-element-field59 form-element-41 default-true form-element-type-checkbox -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Risk factors<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field59\" type=\"checkbox\" data-is-required=\"true\" name=\"field59[]\" value=\"Alcohol\" class=\"validation-lenient\"><span><span >Alcohol<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field59\" type=\"checkbox\" data-is-required=\"true\" name=\"field59[]\" value=\"Smoking\" class=\"validation-lenient\"><span><span >Smoking<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field59\" type=\"checkbox\" data-is-required=\"true\" name=\"field59[]\" value=\"Repeated trauma\" class=\"validation-lenient\"><span><span >Repeated trauma<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field59\" type=\"checkbox\" data-is-required=\"true\" name=\"field59[]\" value=\"Other\" class=\"validation-lenient\"><span><span >Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field60\" data-index=\"42\" style=\"width: 100%; position: relative; z-index: 999; left: 0px; top: 0px\" class=\" form-element form-element-field60 form-element-42 default-true form-element-type-checkbox odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Have you attempted treatment?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field60\" type=\"radio\" data-is-required=\"true\" name=\"field60[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field60\" type=\"radio\" data-is-required=\"true\" name=\"field60[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field61\" data-index=\"43\" style=\"width: 100%\" class=\" even form-element form-element-field61 form-element-43 default-true form-element-type-oneLineText -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If yes, which one?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If yes, which one?\" make-read-only=\"false\" data-field-id=\"field61\" name=\"field61[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field55\" data-index=\"44\" style=\"width: 100%\" class=\" form-element form-element-field55 options-false form-element-44 default-true form-element-type-customText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><h2 >Lichen planus<\/h2><\/div><input type=\"hidden\" name=\"field55\" data-field-id=\"field55\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field62\" data-index=\"45\" style=\"width: 100%\" class=\" even form-element form-element-field62 form-element-45 default-true form-element-type-checkbox -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Reason for consultation<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"White lesion\" class=\"validation-lenient\"><span><span >White lesion<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"Leukoplakia-erythroplakia lesion\" class=\"validation-lenient\"><span><span >Leukoplakia-erythroplakia lesion<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field62\" type=\"checkbox\" data-is-required=\"true\" name=\"field62[]\" value=\"Other\" class=\"validation-lenient\"><span><span >Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field63\" data-index=\"46\" style=\"width: 100%; position: relative; z-index: 999; left: 0px; top: 0px\" class=\" form-element form-element-field63 form-element-46 default-true form-element-type-checkbox odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Symptoms<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field63\" type=\"radio\" data-is-required=\"true\" name=\"field63[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field63\" type=\"radio\" data-is-required=\"true\" name=\"field63[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field64\" data-index=\"47\" style=\"width: 100%\" class=\" even form-element form-element-field64 form-element-47 default-true form-element-type-checkbox -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Have you attempted treatment?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field64\" type=\"radio\" data-is-required=\"true\" name=\"field64[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field64\" type=\"radio\" data-is-required=\"true\" name=\"field64[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field65\" data-index=\"48\" style=\"width: 100%\" class=\" form-element form-element-field65 form-element-48 default-true form-element-type-oneLineText odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If yes, which one?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If yes, which one?\" make-read-only=\"false\" data-field-id=\"field65\" name=\"field65[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field66\" data-index=\"49\" style=\"width: 100%\" class=\" even form-element form-element-field66 options-false form-element-49 default-true form-element-type-customText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #ff0000 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p ><b>Dexamethasone elixir to be taken for 2 weeks + follow-up in 1 month<\/b><\/p><\/div><input type=\"hidden\" name=\"field66\" data-field-id=\"field66\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field54\" data-index=\"50\" style=\"width: 100%\" class=\" form-element form-element-field54 options-false form-element-50 default-true form-element-type-customText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><h2 >Vesiculobullous disease\/desquamative gingivitis<\/h2><\/div><input type=\"hidden\" name=\"field54\" data-field-id=\"field54\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field67\" data-index=\"51\" style=\"width: 100%; position: relative; z-index: 999; left: 0px; top: 0px\" class=\" even form-element form-element-field67 form-element-51 default-true form-element-type-checkbox -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Reason for consultation<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field67\" type=\"checkbox\" data-is-required=\"true\" name=\"field67[]\" value=\"White lesion\" class=\"validation-lenient\"><span><span >White lesion<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field67\" type=\"checkbox\" data-is-required=\"true\" name=\"field67[]\" value=\"Leukoplakia-erythroplakia lesion\" class=\"validation-lenient\"><span><span >Leukoplakia-erythroplakia lesion<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field67\" type=\"checkbox\" data-is-required=\"true\" name=\"field67[]\" value=\"Other\" class=\"validation-lenient\"><span><span >Other<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field68\" data-index=\"52\" style=\"width: 100%\" class=\" form-element form-element-field68 form-element-52 default-true form-element-type-checkbox odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Symptoms<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field68\" type=\"radio\" data-is-required=\"true\" name=\"field68[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field68\" type=\"radio\" data-is-required=\"true\" name=\"field68[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field69\" data-index=\"53\" style=\"width: 100%\" class=\" even form-element form-element-field69 form-element-53 default-true form-element-type-checkbox -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Have you attempted treatment?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field69\" type=\"radio\" data-is-required=\"true\" name=\"field69[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field69\" type=\"radio\" data-is-required=\"true\" name=\"field69[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field70\" data-index=\"54\" style=\"width: 100%\" class=\" form-element form-element-field70 form-element-54 default-true form-element-type-oneLineText odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If yes, which one?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If yes, which one?\" make-read-only=\"false\" data-field-id=\"field70\" name=\"field70[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field71\" data-index=\"55\" style=\"width: 100%\" class=\" even form-element form-element-field71 options-false form-element-55 default-true form-element-type-customText is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #ff0000 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p ><b>Dexamethasone elixir to be taken for 2 weeks + follow-up in 1 month<\/b><\/p><\/div><input type=\"hidden\" name=\"field71\" data-field-id=\"field71\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field53\" data-index=\"56\" style=\"width: 100%\" class=\" form-element form-element-field53 form-element-56 default-true form-element-type-customText is-required-false odd -handle options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><h2 >Other<\/h2><\/div><input type=\"hidden\" name=\"field53\" data-field-id=\"field53\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field72\" data-index=\"57\" style=\"width: 100%\" class=\" even form-element form-element-field72 form-element-57 default-true form-element-type-oneLineText -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Reason for consultation<\/span><\/span><span class=\"sub-label\"><span >votre nom complet<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"Reason for consultation\" make-read-only=\"false\" data-field-id=\"field72\" name=\"field72[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field73\" data-index=\"58\" style=\"width: 100%\" class=\" form-element form-element-field73 form-element-58 default-true form-element-type-checkbox odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Symptoms<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field73\" type=\"radio\" data-is-required=\"true\" name=\"field73[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field73\" type=\"radio\" data-is-required=\"true\" name=\"field73[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field74\" data-index=\"59\" style=\"width: 100%\" class=\" even form-element form-element-field74 form-element-59 default-true form-element-type-checkbox -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Have you attempted treatment?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field74\" type=\"radio\" data-is-required=\"true\" name=\"field74[]\" value=\"Yes\" class=\"validation-lenient\"><span><span >Yes<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field74\" type=\"radio\" data-is-required=\"true\" name=\"field74[]\" value=\"No\" class=\"validation-lenient\"><span><span >No<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field75\" data-index=\"60\" style=\"width: 100%\" class=\" form-element form-element-field75 form-element-60 default-true form-element-type-oneLineText odd -handle is-required-true options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"oneLineText-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >If yes, which one?<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"If yes, which one?\" make-read-only=\"false\" data-field-id=\"field75\" name=\"field75[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-\"><\/i><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field14\" data-index=\"61\" style=\"width: 100%\" class=\" even form-element form-element-field14 form-element-61 default-false form-element-type-checkbox is-required-false -handle options-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Select a doctor<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field14\" type=\"checkbox\" data-is-required=\"false\" name=\"field14[]\" value=\"Any doctor\" class=\"validation-lenient\"><span><span >Any doctor<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field14\" type=\"checkbox\" data-is-required=\"false\" name=\"field14[]\" value=\"Dr Max Miller\" class=\"validation-lenient\"><span><span >Dr Max Miller<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field14\" type=\"checkbox\" data-is-required=\"false\" name=\"field14[]\" value=\"Dr Olivier Handfield\" class=\"validation-lenient\"><span><span >Dr Olivier Handfield<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field14\" type=\"checkbox\" data-is-required=\"false\" name=\"field14[]\" value=\"Dre Annie Quesnel\" class=\"validation-lenient\"><span><span >Dre Annie Quesnel<\/span><\/span><\/label><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field14\" type=\"checkbox\" data-is-required=\"false\" name=\"field14[]\" value=\"Dre Archambault\" class=\"validation-lenient\"><span><span >Dre Archambault<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field11\" data-index=\"62\" style=\"width: 100%\" class=\" form-element form-element-field11 options-false form-element-62 default-false form-element-type-matrix is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"matrix-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Level of emergency<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><table cellspacing=\"0\" cellpadding=\"0\"><thead><tr><th><\/th><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Code 1   very urgent <\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Code 2   semi urgent (4 to 8 weeks)<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Code 3   according to our availability<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Code 4<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><th class=\" \">Code 5<\/th><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><\/thead><tbody><!-- ngRepeat: row in element.elementDefaults.matrixRowsOutput --><tr ><td >Level of emergency<\/td><!-- ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field11_0\" value=\"Code 1   very urgent \"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field11_0\" value=\"Code 2   semi urgent (4 to 8 weeks)\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field11_0\" value=\"Code 3   according to our availability\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field11_0\" value=\"Code 4\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><td ><label><input type=\"radio\" name=\"field11_0\" value=\"Code 5\"><\/label><\/td><!-- end ngRepeat: col in element.elementDefaults.matrixColumnsOutput --><\/tr><!-- end ngRepeat: row in element.elementDefaults.matrixRowsOutput --><\/tbody><\/table><\/div><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field12\" data-index=\"63\" style=\"width: 100%\" class=\" even form-element form-element-field12 options-false form-element-63 default-false form-element-type-textarea is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><label class=\"textarea-cover field-cover \"><span class=\"sub-label-false\"><span class=\"main-label\"><span >Comments<\/span><\/span><span class=\"sub-label\"><\/span><\/span><div><span class=\"error\"><\/span><textarea data-field-id=\"field12\" placeholder=\"Comments\" class=\"validation-lenient\" name=\"field12\" value=\"\" rows=\"5\" data-min-char=\"\" data-max-char=\"\" data-is-required=\"false\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-original-title=\"\" style=\"min-height: 110.781px\"><\/textarea><div class=\"count-\"><span class=\"current-count\">0<\/span> \/ <span class=\"max-count \"><\/span><\/div><\/div><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field6\" data-index=\"64\" style=\"width: 100%\" class=\" form-element form-element-field6 options-false form-element-64 default-false form-element-type-submit is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-left wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><label ><input type=\"text\" class=\"required_field\" name=\"website\" autocomplete=\"maple-syrup-pot\"><\/label><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div><!-- end ngRepeat: page in Builder.FormElements track by $index -->\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 99%; color: #666666; font-size: 100%; background: none\">\n\t\t\t\t<div>\n\t\t\t\t\t\n\t\t\t\t\t<span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div>\n\t\t\t\t\t\n\t\t\t\t\t<span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><\/div>\n<\/div><\/div><\/div><\/div><\/div><div class=\"vc_col-sm-2 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-separator size_custom\" style=\"height:32px\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/section>\n","protected":false},"excerpt":{"rendered":"REFER A PATIENT 1 Step 1 Refering dentist\/physician name Patient name Refering dentist\/physician emaila valid emailemail Patient telephone numberphone Birth dateBirth datedate_range Upload your X-raysuploadcloud_uploadUpload your X-rays Consultation reasonExtractionWisdom teethPre-prosthetic surgeryImplantologyBone graftLaserImpacted tooth exposition and tractionOrthognathic surgeryTMJPathologyFractureInfant frenotomyScanTADS Reason for referralSuspicion of dysplasia\/carcinomaLichen planusVesiculobullous disease\/desquamative gingivitisOther What is your specialty ?DentistFamily DoctorPhysiotherapistOther Reason for the...","protected":false},"author":3,"featured_media":0,"parent":945,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-300","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.3.1 - 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