{"id":719,"date":"2024-09-30T16:26:20","date_gmt":"2024-09-30T16:26:20","guid":{"rendered":"https:\/\/wp250122.wpdns.ca\/?page_id=719"},"modified":"2025-05-08T08:47:58","modified_gmt":"2025-05-08T08:47:58","slug":"referents","status":"publish","type":"page","link":"https:\/\/parozenith.com\/en\/referents\/","title":{"rendered":"MAKE APPOINTMENT \/ REFER A PATIENT"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"719\" class=\"elementor elementor-719\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ceebe08 e-flex e-con-boxed e-con e-parent\" data-id=\"ceebe08\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1160e70 elementor-widget elementor-widget-heading\" data-id=\"1160e70\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">MAKE APPOINTMENT <br>\/ REFER A PATIENT<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a8f4d76 elementor-widget elementor-widget-shortcode\" data-id=\"a8f4d76\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\r\n<div class=\"patient-referral-form-container\">\r\n    <form id=\"patient-referral-form\" enctype=\"multipart\/form-data\" action=\"\">\r\n        <div class=\"form-response\"><\/div>\r\n        \r\n        <div class=\"form-section\">            \r\n            <div class=\"form-group\">\r\n                <label for=\"date\" data-trp-translate-id=\"label-date\">Date et Heure <span><\/span><\/label>\r\n                <input type=\"text\" id=\"date\" name=\"date\" value=\"2026-04-15 04:50:12 PM\" readonly class=\"responsive-date-input\">\r\n            <\/div>\r\n            \r\n            <div class=\"form-row\">\r\n                <div class=\"form-group\">\r\n                    <label for=\"patient_name\" data-trp-translate-id=\"label-patient-name\">Patient Name <span class=\"required\">*<\/span><\/label>\r\n                    <input type=\"text\" id=\"patient_name\" name=\"patient_name\" placeholder=\"Patient Name\" maxlength=\"50\">\r\n                <\/div>\r\n                \r\n                <div class=\"form-group\">\r\n                    <label for=\"patient_phone\" data-trp-translate-id=\"label-patient-phone\">\r\n                        Phone <span class=\"required\">*<\/span>\r\n                    <\/label>\r\n                    <input type=\"tel\" id=\"patient_phone\" name=\"patient_phone\" placeholder=\"Phone\" maxlength=\"50\">\r\n                <\/div>\r\n            <\/div>\r\n        <\/div>\r\n        \r\n        <div class=\"form-section\">\r\n            <div class=\"form-group\">\r\n                <label for=\"dentist_name\" data-trp-translate-id=\"label-dentist-name\">Referring dentist <span class=\"required\">*<\/span><\/label>\r\n                <input type=\"text\" id=\"dentist_name\" name=\"dentist_name\" placeholder=\"Name of dentist\/specialist\" maxlength=\"50\">\r\n            <\/div>\r\n            \r\n            <div class=\"form-row\">\r\n                <div class=\"form-group\">\r\n                    <label for=\"dentist_email\" data-trp-translate-id=\"label-dentist-email\">Dentiste Email <span class=\"required\">*<\/span><\/label>\r\n                    <input type=\"text\" id=\"dentist_email\" name=\"dentist_email\" placeholder=\"Courriel du dentiste\/sp\u00e9cialiste\" maxlength=\"50\">\r\n                <\/div>\r\n                \r\n                <div class=\"form-group\">\r\n                    <label for=\"dentist_phone\" data-trp-translate-id=\"label-dentist-phone\">\r\n                        Dentist Phone <span class=\"required\">*<\/span>\r\n                    <\/label>\r\n                    <input type=\"tel\" id=\"dentist_phone\" name=\"dentist_phone\" placeholder=\"T\u00e9l\u00e9phone du dentiste\/sp\u00e9cialiste\" maxlength=\"50\">\r\n                <\/div>\r\n            <\/div>\r\n        <\/div>\r\n        \r\n        <div class=\"form-section\">\r\n            <div class=\"form-group checkbox-group\">\r\n                <label data-trp-translate-id=\"label-visit-reasons\">Reason for the Visit <span class=\"required\">*<\/span><\/label>\r\n                <div class=\"checkbox-options\">\r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_evaluation\" name=\"visit_reasons[]\" value=\"\u00c9valuation compl\u00e8te\">\r\n                        <label for=\"reason_evaluation\" data-trp-translate-id=\"label-reason-evaluation\">\r\n                            Complete Evaluation                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_urgence\" name=\"visit_reasons[]\" value=\"Traitement d&#039;urgence\">\r\n                        <label for=\"reason_urgence\" data-trp-translate-id=\"label-reason-urgence\">\r\n                            Emergency Treatment                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_chirurgie\" name=\"visit_reasons[]\" value=\"Chirurgie osseuse\">\r\n                        <label for=\"reason_chirurgie\" data-trp-translate-id=\"label-reason-chirurgie\">\r\n                            Bone Surgery                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_regeneration\" name=\"visit_reasons[]\" value=\"R\u00e9g\u00e9n\u00e9ration tissulaire guid\u00e9e\">\r\n                        <label for=\"reason_regeneration\" data-trp-translate-id=\"label-reason-regeneration\">\r\n                            Guided Tissue Regeneration                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_greffe\" name=\"visit_reasons[]\" value=\"Greffe gingivale\">\r\n                        <label for=\"reason_greffe\" data-trp-translate-id=\"label-reason-greffe\">\r\n                            Gingival Graft                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_extraction\" name=\"visit_reasons[]\" value=\"Extraction et greffe osseuse\">\r\n                        <label for=\"reason_extraction\" data-trp-translate-id=\"label-reason-extraction\">\r\n                            Extraction and Bone Graft                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_reconstruction\" name=\"visit_reasons[]\" value=\"Reconstruction alv\u00e9olaire osseuse\">\r\n                        <label for=\"reason_reconstruction\" data-trp-translate-id=\"label-reason-reconstruction\">\r\n                            Alveolar Bone Reconstruction                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_comblement\" name=\"visit_reasons[]\" value=\"Comblement sinusien\">\r\n                        <label for=\"reason_comblement\" data-trp-translate-id=\"label-reason-comblement\">\r\n                            Sinus Lift                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_implant\" name=\"visit_reasons[]\" value=\"Implant dentaire\">\r\n                        <label for=\"reason_implant\" data-trp-translate-id=\"label-reason-implant\">\r\n                            Dental Implant                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_peri\" name=\"visit_reasons[]\" value=\"P\u00e9ri-implantite\">\r\n                        <label for=\"reason_peri\" data-trp-translate-id=\"label-reason-peri\">\r\n                            Peri-implantitis                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_elongation\" name=\"visit_reasons[]\" value=\"\u00c9longation coronaire\">\r\n                        <label for=\"reason_elongation\" data-trp-translate-id=\"label-reason-elongation\">\r\n                            Crown Lengthening                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_exposition\" name=\"visit_reasons[]\" value=\"Exposition de dent incluse\">\r\n                        <label for=\"reason_exposition\" data-trp-translate-id=\"label-reason-exposition\">\r\n                            Exposure of Impacted Tooth                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_frenectomie\" name=\"visit_reasons[]\" value=\"Fr\u00e9nectomie\">\r\n                        <label for=\"reason_frenectomie\" data-trp-translate-id=\"label-reason-frenectomie\">\r\n                            Frenectomy                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_biopsie\" name=\"visit_reasons[]\" value=\"Biopsie\">\r\n                        <label for=\"reason_biopsie\" data-trp-translate-id=\"label-reason-biopsie\">\r\n                            Biopsy                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"checkbox-wrapper\">\r\n                        <input type=\"checkbox\" id=\"reason_autre\" name=\"visit_reasons[]\" value=\"Autre\">\r\n                        <label for=\"reason_autre\" data-trp-translate-id=\"label-reason-autre\">\r\n                            Other (specify below)                        <\/label>\r\n                    <\/div>\r\n                <\/div>\r\n            <\/div>\r\n            \r\n            <div class=\"form-group\">\r\n                <label for=\"other_reason\" data-trp-translate-id=\"label-other-reason\">Other <span><\/span><\/label>\r\n                <input type=\"text\" id=\"other_reason\" name=\"other_reason\" placeholder=\"Other\" maxlength=\"50\">\r\n            <\/div>\r\n            \r\n            <div class=\"form-group\">\r\n                <label for=\"tooth_number\" data-trp-translate-id=\"label-tooth-number\">Tooth or Area Number <span><\/span><\/label>\r\n                <input type=\"text\" id=\"tooth_number\" name=\"tooth_number\" placeholder=\"Num\u00e9ro de la dent ou de la r\u00e9gion\" maxlength=\"50\">\r\n            <\/div>\r\n            \r\n            <div class=\"form-group radio-group\">\r\n                <label data-trp-translate-id=\"label-appointment\">Appointment <span><\/span><\/label>\r\n                <div class=\"radio-options\">\r\n                    <!-- Each radio option now properly wrapped in its own div -->\r\n                    <div class=\"radio-option-wrapper\">\r\n                        <input type=\"radio\" id=\"appointment_type_1\" name=\"appointment_type\" value=\"SVP communiquer avec le\/la patient(e) pour un rendez-vous\">\r\n                        <label for=\"appointment_type_1\" data-trp-translate-id=\"label-appointment-type-1\">\r\n                            The patient will call for an appointment.                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"radio-option-wrapper\">\r\n                        <input type=\"radio\" id=\"appointment_type_2\" name=\"appointment_type\" value=\"Le\/la patient(e) appellera pour un rendez-vous\">\r\n                        <label for=\"appointment_type_2\" data-trp-translate-id=\"label-appointment-type-2\">\r\n                            Le\/la patient(e) appellera pour un rendez-vous                        <\/label>\r\n                    <\/div>\r\n                <\/div>\r\n            <\/div>\r\n\r\n            <div class=\"form-group radio-group\">\r\n                <label data-trp-translate-id=\"label-radiography\">\r\n                    Radiography <span><\/span>\r\n                <\/label>\r\n                <div class=\"radio-options\">\r\n                    <div class=\"radio-option-wrapper\">\r\n                        <input type=\"radio\" id=\"radiography_type_1\" name=\"radiography_type\" value=\"Remises au(\u00e0 la) patient(e)\">\r\n                        <label for=\"radiography_type_1\" data-trp-translate-id=\"label-radiography-type-1\">\r\n                            Given to the patient                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"radio-option-wrapper\">\r\n                        <input type=\"radio\" id=\"radiography_type_2\" name=\"radiography_type\" value=\"Aucune radiographie disponible\">\r\n                        <label for=\"radiography_type_2\" data-trp-translate-id=\"label-radiography-type-2\">\r\n                            No radiography available                        <\/label>\r\n                    <\/div>\r\n                    \r\n                    <div class=\"radio-option-wrapper\">\r\n                        <input type=\"radio\" id=\"radiography_type_3\" name=\"radiography_type\" value=\"Je vais charger un dossier zip maintenant\">\r\n                        <label for=\"radiography_type_3\" data-trp-translate-id=\"label-radiography-type-3\">\r\n                            I will upload a zip file now                        <\/label>\r\n                    <\/div>\r\n                <\/div>\r\n            <\/div>\r\n        <\/div>\r\n        \r\n        <div class=\"form-section attachments-section\">\r\n            <label data-trp-translate-id=\"label-file-upload\">Upload Files <span><\/span><\/label>\r\n            \r\n            <div class=\"form-group file-upload-group\">\r\n                <input type=\"file\" id=\"attachments\" name=\"attachments[]\" multiple>\r\n                <div id=\"selected-files\"><\/div>\r\n            <\/div>\r\n            <div id=\"file-errors\" class=\"file-error-message\"><\/div>\r\n        <\/div>\r\n        \r\n        <div class=\"form-section\">\r\n            <div class=\"form-group\">\r\n                <label for=\"comments\" data-trp-translate-id=\"label-comments\">Comments <span><\/span><\/label>\r\n                <textarea id=\"comments\" name=\"comments\" rows=\"4\" placeholder=\"Votre commentaire\" maxlength=\"500\"><\/textarea>\r\n            <\/div>\r\n        <\/div>\r\n        \r\n        <div class=\"form-actions\">\r\n            <input type=\"hidden\" name=\"action\" value=\"submit_patient_referral\">\r\n            <input type=\"hidden\" name=\"nonce\" value=\"944a82d19b\">\r\n            <input type=\"hidden\" name=\"submission_id\" value=\"prs_69dffa047d869\">\r\n            <button type=\"submit\" class=\"submit-button\" data-trp-translate-id=\"button-submit\">Send <span><\/span><\/button>\r\n        <\/div>\r\n    <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\r\n<\/div><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b1e051f elementor-widget elementor-widget-text-editor\" data-id=\"b1e051f\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><a style=\"background-color: #5d7790; color: white; transition-property: all;\" href=\"https:\/\/immaxquebec.com\/\" target=\"_blank\" rel=\"noopener\">https:\/\/immaxquebec.com\/<\/a><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fd8831d elementor-widget elementor-widget-image\" data-id=\"fd8831d\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/immaxquebec.com\/\" target=\"_blank\" rel=\"noopener\">\n\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"808\" height=\"234\" src=\"https:\/\/parozenith.com\/wp-content\/uploads\/2024\/09\/manon_certification_temp.jpeg\" class=\"attachment-large size-large wp-image-734\" alt=\"Manon attestation\" srcset=\"https:\/\/parozenith.com\/wp-content\/uploads\/2024\/09\/manon_certification_temp.jpeg 808w, https:\/\/parozenith.com\/wp-content\/uploads\/2024\/09\/manon_certification_temp-300x87.jpeg 300w, https:\/\/parozenith.com\/wp-content\/uploads\/2024\/09\/manon_certification_temp-768x222.jpeg 768w\" sizes=\"(max-width: 808px) 100vw, 808px\" \/>\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>PRENDRE RENDEZ-VOUS \/ R\u00c9F\u00c9RER UN PATIENT https:\/\/immaxquebec.com\/<\/p>","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center 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