{"id":623,"date":"2025-05-28T10:22:54","date_gmt":"2025-05-28T15:22:54","guid":{"rendered":"https:\/\/giggleskidsdental.ca\/?page_id=623"},"modified":"2025-09-17T10:02:16","modified_gmt":"2025-09-17T15:02:16","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/giggleskidsdental.ca\/fr\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"<div id=\"cs-content\" class=\"cs-content\"><div class=\"x-section e623-e1 mhb-0\"><div class=\"x-row x-container max width e623-e2 mhb-3 mhb-4 mhb-6\"><div class=\"x-row-inner\"><div class=\"x-col e623-e3 mhb-8 mhb-9\"><div class=\"x-text x-text-headline e623-e4 mhb-d\"><div class=\"x-text-content\"><div class=\"x-text-content-text\"><h1 class=\"x-text-content-text-primary\">Complete the referral in the way that works best for you<\/h1>\n<\/div><\/div><\/div><\/div><div class=\"x-col e623-e5 mhb-8 mhb-a mhb-b\"><a class=\"x-anchor x-anchor-button e623-e6-v0 mhb-e mhb-f mhb-1\" tabindex=\"0\" style=\"--tco-dchb-1:#f9dd0d;--tco-dchb-4:#bce6fc;--tco-dchb-5:#000000;--tco-dchb-8:#000000;\" href=\"#referralform\" target=\"_self\"><div class=\"x-anchor-content\"><div class=\"x-anchor-text\"><span class=\"x-anchor-text-primary\">Fill out form<\/span><\/div><\/div><\/a><a class=\"x-anchor x-anchor-button e623-e7-v0 mhb-f mhb-g mhb-2\" tabindex=\"0\" style=\"--tco-dchb-a:#bce6fc;--tco-dchb-d:#f9dd0d;--tco-dchb-e:#000000;--tco-dchb-h:#000000;\" href=\"\/wp-content\/uploads\/2025\/09\/Giggles-Fillable-PDF-Final.pdf\" target=\"Same Tab\"><div class=\"x-anchor-content\"><div class=\"x-anchor-text\"><span class=\"x-anchor-text-primary\">Download PDF<\/span><\/div><\/div><\/a><\/div><\/div><\/div><div class=\"x-row x-container max width e623-e8 mhb-3 mhb-5 mhb-7\" id=\"referralform\"><div class=\"x-row-inner\"><div class=\"x-col e623-e9 mhb-8 mhb-9 mhb-a mhb-c\"><div class=\"x-form-integration x-form-integration-gravity-forms e623-e10 mhb-h\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\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_3' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/fr\/wp-json\/wp\/v2\/pages\/623' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_3_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PATIENT INFORMATION<\/h3><\/div><div id=\"field_3_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-two-thirds gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_44'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_3_44' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_15'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_3_15' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_15_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_15_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_15' class='gform_hidden' value='https:\/\/giggleskidsdental.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_43'>Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_3_43' type='text' value='' class='large' maxlength='100'    aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_16\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_16'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_3_16' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_53\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_53'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_53' id='input_3_53' type='email' value='' class='large'     aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><div id=\"field_3_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_42'>Parent\/Guardian&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_3_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/><\/div><div id=\"field_3_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">REFERRING DOCTOR INFORMATION<\/h3><\/div><div id=\"field_3_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_1'>Referring Doctor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_3_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_6'>Practice Name<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_3_6' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_41'>Office Address<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_3_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_8'>Office Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_3_8' type='tel' value='' class='large'    aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_7'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_3_7' type='email' value='' class='large'     aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><div id=\"field_3_52\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_52'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_3_52' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_3_52_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_3_52_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_52' class='gform_hidden' value='https:\/\/giggleskidsdental.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_3_51\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/><\/div><div id=\"field_3_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">REASON FOR REFERRAL (CHECK ALL THAT APPLY)<\/h3><\/div><fieldset id=\"field_3_32\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_4col gfield--width-full field_sublabel_above gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reason for Referral<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_3_32'><div class='gchoice gchoice_3_32_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.1' type='checkbox'  value='Pain'  id='choice_3_32_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_1' id='label_3_32_1' class='gform-field-label gform-field-label--type-inline'>Pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.2' type='checkbox'  value='Anxiety'  id='choice_3_32_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_2' id='label_3_32_2' class='gform-field-label gform-field-label--type-inline'>Anxiety<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.3' type='checkbox'  value='Medical Concerns'  id='choice_3_32_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_3' id='label_3_32_3' class='gform-field-label gform-field-label--type-inline'>Medical Concerns<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.4' type='checkbox'  value='Previous Negative Experience'  id='choice_3_32_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_4' id='label_3_32_4' class='gform-field-label gform-field-label--type-inline'>Previous Negative Experience<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.5' type='checkbox'  value='General Anesthetic'  id='choice_3_32_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_5' id='label_3_32_5' class='gform-field-label gform-field-label--type-inline'>General Anesthetic<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.6' type='checkbox'  value='Restorative Work Required'  id='choice_3_32_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_6' id='label_3_32_6' class='gform-field-label gform-field-label--type-inline'>Restorative Work Required<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.7' type='checkbox'  value='Eruption'  id='choice_3_32_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_7' id='label_3_32_7' class='gform-field-label gform-field-label--type-inline'>Eruption<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.8' type='checkbox'  value='Habits'  id='choice_3_32_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_8' id='label_3_32_8' class='gform-field-label gform-field-label--type-inline'>Habits<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_32_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_32.9' type='checkbox'  value='Other'  id='choice_3_32_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_32_9' id='label_3_32_9' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_35'>Please Specify Other<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_3_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_47\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><hr\/><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">RADIOGRAPHS<\/h3><\/div><fieldset id=\"field_3_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Please forward radiographs prior to appointment<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_20'>\n\t\t\t<div class='gchoice gchoice_3_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Included'  id='choice_3_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_0' id='label_3_20_0' class='gform-field-label gform-field-label--type-inline'>Included<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Emailed'  id='choice_3_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_1' id='label_3_20_1' class='gform-field-label gform-field-label--type-inline'>Emailed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Please call patient'  id='choice_3_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_2' id='label_3_20_2' class='gform-field-label gform-field-label--type-inline'>Please call patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_20_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Please call office'  id='choice_3_20_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_3_20_3' id='label_3_20_3' class='gform-field-label gform-field-label--type-inline'>Please call office<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div 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