{"id":2752,"date":"2022-05-05T09:54:05","date_gmt":"2022-05-04T23:54:05","guid":{"rendered":"https:\/\/theperiospecialists.com.au\/?page_id=2752"},"modified":"2024-12-17T16:26:17","modified_gmt":"2024-12-17T06:26:17","slug":"online-referrals","status":"publish","type":"page","link":"https:\/\/goldcoastperiodontist.com.au\/staging\/online-referrals\/","title":{"rendered":"Online Referrals"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column][tm_spacer size=&#8221;lg:32&#8243;][\/vc_column][\/vc_row][vc_row lg_spacing=&#8221;padding_bottom:100&#8243;][vc_column width=&#8221;1\/2&#8243; custom_border_color=&#8221;&#8221; content_alignment=&#8221;center&#8221; lg_spacing=&#8221;padding_right:100&#8243; sm_spacing=&#8221;padding_top:30;padding_right:30;padding_bottom:30;padding_left:30&#8243; xs_spacing=&#8221;padding_top:30;padding_right:30;padding_bottom:30;padding_left:30&#8243;][tm_image align=&#8221;center&#8221; custom_border_color=&#8221;&#8221; image=&#8221;4491&#8243;][\/vc_column][vc_column width=&#8221;1\/2&#8243; sm_content_alignment=&#8221;center&#8221; xs_content_alignment=&#8221;center&#8221;][tm_heading tag=&#8221;h2&#8243; custom_google_font=&#8221;&#8221; text=&#8221;Assisting General Dental Providers&#8221;][tm_spacer size=&#8221;lg:32&#8243;][vc_column_text css_animation=&#8221;fadeIn&#8221;]Specialist Dentistry is here to assist you and your patients in achieving the best and healthiest smile.<\/p>\n<p>Complete the form below to refer your patient to Specialist Dentistry. Once received, our team will review the information and contact you on next steps and supply of relevant documentation.<\/p>\n<p>If you would like a referral pack or to discuss a patient case, please contact our friendly reception team today.[\/vc_column_text][\/vc_column][\/vc_row][vc_row full_width=&#8221;stretch_row&#8221; background_color=&#8221;primary&#8221; lg_spacing=&#8221;padding_top:64;padding_bottom:64&#8243;][vc_column el_class=&#8221;referrals&#8221;][tm_heading tag=&#8221;h2&#8243; custom_google_font=&#8221;&#8221; align=&#8221;center&#8221; text_color=&#8221;custom&#8221; custom_text_color=&#8221;#f6f1ec&#8221; animation=&#8221;move-up&#8221; text=&#8221;Online Referral&#8221;][tm_spacer size=&#8221;lg:20&#8243;]<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/staging\/wp-json\/wp\/v2\/pages\/2752' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_17\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>Referral Treatment Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_17'>Please select one of the following:<\/div><div class='ginput_container ginput_container_select'><select name='input_17' id='input_4_17' class='large gfield_select'  aria-describedby=\"gfield_description_4_17\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Endodontic Treatment' selected='selected'>Endodontic Treatment<\/option><option value='Periodontics' >Periodontics<\/option><option value='Orofacial Myology' >Orofacial Myology<\/option><option value='Oral Surgery and Trauma' >Oral Surgery and Trauma<\/option><option value='Dental Implants' >Dental Implants<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_4_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_25\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1>Patient Details<\/h1><\/div><div id=\"field_4_31\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_1'>Patient First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_4_1' type='text' value='' class='large'    placeholder='Patient First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_3'>Patient Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_4_3' type='text' value='' class='large'    placeholder='Patient Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_21\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'>Patient DOB<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_4_21' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='Patient DOB' aria-describedby=\"input_4_21_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_21_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_21' class='gform_hidden' value='https:\/\/goldcoastperiodontist.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_4'>Patient Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_4_4' type='text' value='' class='large'    placeholder='Patient Phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_33\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_33'>Provider<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_4_33' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Dr Jason Bulmer' >Dr Jason Bulmer<\/option><option value='Dr Alexander McDonald' >Dr Alexander McDonald<\/option><option value='Dr Dan Allan' >Dr Dan Allan<\/option><option value='Dr Georgios (George) Papageorgakopoulos' >Dr Georgios (George) Papageorgakopoulos<\/option><\/select><\/div><\/div><div id=\"field_4_22\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_22'>Patient Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_4_22' type='email' value='' class='large'   placeholder='Patient Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_27\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_27'>Reason for Referral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_27'>Please include any relevant medical history<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_27' id='input_4_27' class='textarea large'  aria-describedby=\"gfield_description_4_27\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_26\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1>Referral Details<\/h1><\/div><div id=\"field_4_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_5'>Referring Practice<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_4_5' type='text' value='' class='large'    placeholder='Referring Practice' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_9'>Referring Provider First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_4_9' type='text' value='' class='large'    placeholder='Referring Provider First Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_10'>Referring Provider Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_4_10' type='text' value='' class='large'    placeholder='Referring Provider Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_20\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_20'>Practice Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_20' id='input_4_20' type='email' value='' class='large'   placeholder='Practice Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'>Practice Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_4_6' type='text' value='' class='large'    placeholder='Practice Phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Is a post space required?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_28'><div class='gchoice gchoice_4_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Yes'  id='choice_4_28_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_1' id='label_4_28_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='No'  id='choice_4_28_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_2' id='label_4_28_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='At Endodontist discretion'  id='choice_4_28_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_3' id='label_4_28_3' class='gform-field-label gform-field-label--type-inline'>At Endodontist discretion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Not applicable'  id='choice_4_28_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_4' id='label_4_28_4' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Restoration Preference<\/legend><div class='gfield_description' id='gfield_description_4_29'>We will endeavour to place a permanent core restoration at the completion of treatment for your convenience.<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_29'><div class='gchoice gchoice_4_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Place Permanent Core'  id='choice_4_29_1'   aria-describedby=\"gfield_description_4_29\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_1' id='label_4_29_1' class='gform-field-label gform-field-label--type-inline'>Place Permanent Core<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='Place Temporary Restoration'  id='choice_4_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_2' id='label_4_29_2' class='gform-field-label gform-field-label--type-inline'>Place Temporary Restoration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='Place Post (if required)'  id='choice_4_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_3' id='label_4_29_3' class='gform-field-label gform-field-label--type-inline'>Place Post (if required)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='Not applicable'  id='choice_4_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_29_4' id='label_4_29_4' class='gform-field-label gform-field-label--type-inline'>Not applicable<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you done a previous sleep study?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_36'><div class='gchoice gchoice_4_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Yes'  id='choice_4_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_36_1' id='label_4_36_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='No'  id='choice_4_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_36_2' id='label_4_36_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Unsure'  id='choice_4_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_36_3' id='label_4_36_3' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are radiographs enclosed (attached below)?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_37'><div class='gchoice gchoice_4_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Yes'  id='choice_4_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_37_1' id='label_4_37_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='No'  id='choice_4_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_37_2' id='label_4_37_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_37_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.3' type='checkbox'  value='Can not upload'  id='choice_4_37_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_37_3' id='label_4_37_3' class='gform-field-label gform-field-label--type-inline'>Can not upload<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Additional Notes?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_38'><div class='gchoice gchoice_4_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='Blood Thinners'  id='choice_4_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_38_1' id='label_4_38_1' class='gform-field-label gform-field-label--type-inline'>Blood Thinners<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='Bisphosphonates\/Prolia'  id='choice_4_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_38_2' id='label_4_38_2' class='gform-field-label gform-field-label--type-inline'>Bisphosphonates\/Prolia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Methotrexate'  id='choice_4_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_38_3' id='label_4_38_3' class='gform-field-label gform-field-label--type-inline'>Methotrexate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Immune Suppressants'  id='choice_4_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_38_4' id='label_4_38_4' class='gform-field-label gform-field-label--type-inline'>Immune Suppressants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Limited Access'  id='choice_4_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_38_5' id='label_4_38_5' class='gform-field-label gform-field-label--type-inline'>Limited Access<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Anxiety\/Phobia'  id='choice_4_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_38_6' id='label_4_38_6' class='gform-field-label gform-field-label--type-inline'>Anxiety\/Phobia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_39\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are radiographs enclosed (attached below)?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_39'><div class='gchoice gchoice_4_39_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.1' type='checkbox'  value='Yes'  id='choice_4_39_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_1' id='label_4_39_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.2' type='checkbox'  value='No'  id='choice_4_39_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_2' id='label_4_39_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_39_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_39.3' type='checkbox'  value='Can not upload'  id='choice_4_39_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_39_3' id='label_4_39_3' class='gform-field-label gform-field-label--type-inline'>Can not upload<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Additional Notes?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_40'><div class='gchoice gchoice_4_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Blood Thinners'  id='choice_4_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_40_1' id='label_4_40_1' class='gform-field-label gform-field-label--type-inline'>Blood Thinners<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_40_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.2' type='checkbox'  value='Bisphosphonates\/Prolia'  id='choice_4_40_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_40_2' id='label_4_40_2' class='gform-field-label gform-field-label--type-inline'>Bisphosphonates\/Prolia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_40_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.3' type='checkbox'  value='Methotrexate'  id='choice_4_40_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_40_3' id='label_4_40_3' class='gform-field-label gform-field-label--type-inline'>Methotrexate<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_40_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.4' type='checkbox'  value='Immune Suppressants'  id='choice_4_40_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_40_4' id='label_4_40_4' class='gform-field-label gform-field-label--type-inline'>Immune Suppressants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_40_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.5' type='checkbox'  value='Limited Access'  id='choice_4_40_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_40_5' id='label_4_40_5' class='gform-field-label gform-field-label--type-inline'>Limited Access<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_40_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.6' type='checkbox'  value='Anxiety\/Phobia'  id='choice_4_40_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_40_6' id='label_4_40_6' class='gform-field-label gform-field-label--type-inline'>Anxiety\/Phobia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Are radiographs enclosed (attached below)?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_41'><div class='gchoice gchoice_4_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Yes'  id='choice_4_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_1' id='label_4_41_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.2' type='checkbox'  value='No'  id='choice_4_41_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_2' id='label_4_41_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_4_41_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.3' type='checkbox'  value='Can not upload'  id='choice_4_41_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_41_3' id='label_4_41_3' class='gform-field-label gform-field-label--type-inline'>Can not upload<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_23\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_4_23'>Attachment Uploads<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_4_23' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_4_23&quot;,&quot;container&quot;:&quot;gform_multifile_upload_4_23&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_4_23&quot;,&quot;filelist&quot;:&quot;gform_preview_4_23&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/goldcoastperiodontist.com.au\\\/staging\\\/?gf_page=6a37a22063f1bf9&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/goldcoastperiodontist.com.au\\\/staging\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/goldcoastperiodontist.com.au\\\/staging\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;1073741824b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:4,&quot;field_id&quot;:23},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_4_23&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_4_23' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_4_23' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_4_23 gfield_description_4_23\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_23'>Max. file size: 1 GB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_4_23'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_4_23' class='ginput_preview_list'><\/div><div class='gfield_description' id='gfield_description_4_23'>Medical History, etc.<\/div><\/div><div id=\"field_4_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_30'>Additional Comments<\/label><div class='gfield_description' id='gfield_description_4_30'>Any additional information, please provide below.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_4_30' class='textarea large'  aria-describedby=\"gfield_description_4_30\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send Message'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' 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jQuery(this).contents().find('#gform_wrapper_4');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_4').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_4').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_4').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_4').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_4').val();gformInitSpinner( 4, 'https:\/\/goldcoastperiodontist.com.au\/staging\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [4, current_page]);window['gf_submitting_4'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_4').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [4]);window['gf_submitting_4'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_4').text());}else{jQuery('#gform_4').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"4\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_4\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_4\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_4\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 4, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) 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attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n[\/vc_column][\/vc_row][vc_row lg_spacing=&#8221;padding_top:100;padding_bottom:100&#8243;][vc_column][tm_heading custom_google_font=&#8221;&#8221; align=&#8221;center&#8221; text=&#8221;Resource Centre&#8221;][tm_spacer size=&#8221;lg:32&#8243;][tm_blog style=&#8221;carousel_01&#8243; carousel_nav=&#8221;5&#8243; carousel_pagination=&#8221;1&#8243; carousel_gutter=&#8221;30&#8243; number=&#8221;6&#8243; carousel_items_display=&#8221;xs:1;sm:2;md:3;lg:3&#8243;][\/vc_column][\/vc_row][vc_row][vc_column]<div class=\"templatera_shortcode\"><div id=\"tm-row-6ae7ddd357623\" data-vc-full-width=\"true\" data-vc-full-width-init=\"false\" class=\"vc_row vc_row-outer vc_row-fluid\"><div id=\"tm-column-6ae7ddd357e83\" class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner \"><div class=\"wpb_wrapper\">\n<div class=\"tm-heading  center tm-animation move-up\" id=\"tm-heading-6ae7ddd3580cf\">\n\t<h3 class=\"heading\" >How Can We Help?<\/h3><\/div>\n\n<div class=\"tm-spacer\" id=\"tm-spacer-6ae7ddd35838f\"><\/div>\n<div id=\"tm-row-inner-6ae7ddd358bf4\" class=\"vc_row vc_inner vc_row-fluid\"><div id=\"tm-column-inner-6ae7ddd359188\" class=\"wpb_column vc_column_container vc_col-sm-2\"><div class=\"vc_column-inner \"><div class=\"wpb_wrapper\"><\/div><\/div><\/div><div id=\"tm-column-inner-6ae7ddd35931c\" class=\"howcanwehelp wpb_column vc_column_container vc_col-sm-8\"><div class=\"vc_column-inner \"><div class=\"wpb_wrapper\">\n<div class=\"tm-heading  center tm-animation move-up\" id=\"tm-heading-6ae7ddd359489\">\n\t<div class=\"heading\" >Taking the first step on your treatment journey has never been easier. Simply fill out the form below and one of our friendly reception team will get back to you.<\/div><\/div>\n\n<div class=\"tm-spacer\" id=\"tm-spacer-6ae7ddd359636\"><\/div>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' ><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/staging\/wp-json\/wp\/v2\/pages\/2752' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_1\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_1'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_1_1' type='text' value='' class='large'    placeholder='Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_3\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'>Contact Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_1_3' type='text' value='' class='large'    placeholder='Contact Number' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_2\" class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_2'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_1_2' type='email' value='' class='large'   placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Contact Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_1_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Contact Method<\/option><option value='Email Only' >Email Only<\/option><option value='Phone Only' >Phone Only<\/option><option value='Both' >Both<\/option><\/select><\/div><\/div><div id=\"field_1_9\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_1_9' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select a location.<\/option><option value='Carrara' >Carrara<\/option><\/select><\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Please tell us about your oral health concerns<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_1_8' class='textarea small'   maxlength='150' placeholder='Please tell us about your oral health concerns'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Comments<\/label><div class='ginput_container'><input name='input_10' id='input_1_10' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_10'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send Message'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='gravity-theme' \/>\n            <input type='hidden' 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Complete the form below to refer your patient to Specialist Dentistry. Once received, our team will review the information and contact you on next steps and supply of relevant documentation. If you would like a referral pack or to discuss a patient case, please contact our friendly reception team today. Online Referral Referral Treatment Type(Required)Please select one of the following:Endodontic TreatmentPeriodonticsOrofacial MyologyOral Surgery and TraumaDental ImplantsOtherPatient DetailsPatient First Name(Required)Patient Last Name(Required)Patient DOB(Required) DD slash MM slash YYYY Patient Phone(Required)Provider(Required)Dr Jason BulmerDr Alexander McDonaldDr Dan AllanDr Georgios (George) PapageorgakopoulosPatient Email(Required) Reason for Referral(Required)Please include any relevant medical historyReferral DetailsReferring Practice(Required)Referring Provider First Name(Required)Referring Provider Last Name(Required)Practice Email(Required) Practice Phone(Required)Is a post space required? Yes No At Endodontist discretion Not applicable Restoration PreferenceWe will endeavour to place a permanent core restoration at the completion of treatment for your convenience. Place Permanent Core Place Temporary Restoration Place Post (if required) Not applicable Have you done a previous sleep study? Yes No Unsure Are radiographs enclosed (attached below)? Yes No Can not upload Additional Notes? Blood Thinners Bisphosphonates\/Prolia Methotrexate Immune Suppressants Limited Access Anxiety\/Phobia Are radiographs enclosed (attached below)? Yes No Can not upload Additional Notes? Blood Thinners Bisphosphonates\/Prolia Methotrexate Immune Suppressants Limited Access Anxiety\/Phobia Are radiographs enclosed (attached below)? Yes No Can not upload Attachment Uploads Drop files here or Select files Max. file size: 1 GB. Medical History, etc.Additional CommentsAny additional information, please provide below. Resource Centre What is Orofacial Myology? Jul 21, 2025 A Publication by Dr Jason Bulmer May 01, 2025 Endodontic Microsurgery Feb 10, 2025 Understanding Endodontics Jan 10, 2025 Classification of periodontal health and conditions Sep 13, 2022 Periodontal Health Aug 31, 2022 How Can We Help? Taking the first step on your treatment journey has never been easier. Simply fill out the form below and one of our friendly reception team will get back to you. Name(Required)Contact Number(Required)Email(Required) Contact Method(Required)Contact MethodEmail OnlyPhone OnlyBothLocation(Required)Please select a location.CarraraPlease tell us about your oral health concernsEmailThis field is for validation purposes and should be left unchanged. Book Now Click here to book an appointment with one of our specialists. 07 5651 7374 Contact our friendly team to schedule your next appointment. Find Us Carrara Village Shopping Centre, Shop 10 \/ 1 Manchester Rd, Carrara New Patients Find out more about our team","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-2752","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/pages\/2752","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/comments?post=2752"}],"version-history":[{"count":58,"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/pages\/2752\/revisions"}],"predecessor-version":[{"id":5580,"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/pages\/2752\/revisions\/5580"}],"wp:attachment":[{"href":"https:\/\/goldcoastperiodontist.com.au\/staging\/wp-json\/wp\/v2\/media?parent=2752"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}