{"id":445,"date":"2022-05-02T17:35:52","date_gmt":"2022-05-02T17:35:52","guid":{"rendered":"https:\/\/www.apollo-ortho.nl\/?page_id=445"},"modified":"2022-07-13T14:59:53","modified_gmt":"2022-07-13T14:59:53","slug":"referral","status":"publish","type":"page","link":"https:\/\/www.apollo-ortho.nl\/en\/referral\/","title":{"rendered":"Referral"},"content":{"rendered":"\n<p><strong>Dear Doctor,<\/strong><\/p>\n\n\n\n<p><strong>Thank you for referring your patient to our orthodontic practice! You can use the form below for this, then we will receive the referral digitally in the mail.<\/strong><\/p>\n\n\n\n<p><strong>Team Apollo &#8211; Dentists for orthodontics<\/strong><\/p>\n\n\n\n<p>*If desired, after submitting the form, you can download a PDF file of the referral form and send it to your patient, so that he\/she is also aware of what information has been provided to us from your practice .<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Referral form<\/h3>\n\n\n<!-- HTML Forms v1.5.3 - https:\/\/wordpress.org\/plugins\/html-forms\/ -->\n<form method=\"post\"  class=\"hf-form hf-form-607 \" data-id=\"607\" data-title=\"Verwijsformulier__EN\" data-slug=\"verwijsformulier__en\" data-message-success=\"Thank you! We will be in touch soon.\" data-message-invalid-email=\"Sorry, that email address looks invalid.\" data-message-required-field-missing=\"Please fill in the required fields.\" data-message-error=\"Oops. An error occurred.\"><input type=\"hidden\" name=\"_hf_form_id\" value=\"607\" \/><div style=\"display: none;\"><input type=\"text\" name=\"_hf_h607\" value=\"\" \/><\/div><div class=\"hf-fields-wrap\"><div class=\"grid lg:grid-cols-2 gap-[30px] referral-form\">\r\n\r\n\t<div>\r\n\t\t<label for=\"first-name\" class=\"block mb-2\">First name*<\/label>\r\n\t\t<input type=\"text\" name=\"first-name\" id=\"first-name\" placeholder=\"Vul uw voornaam in\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"last-name\" class=\"block mb-2\">Last name*<\/label>\r\n\t\t<input type=\"text\" name=\"last-name\" id=\"last-name\" placeholder=\"Vul uw achternaam in\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div>\r\n\t\t<label for=\"postcode\" class=\"block mb-2\">Postal code + house number client*<\/label>\r\n\t\t<input type=\"text\" name=\"postcode\" id=\"postcode\" placeholder=\"Vul uw achternaam in\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"birth-date\" class=\"block mb-2\">Date of birth*<\/label>\r\n\t\t<input type=\"date\" name=\"birth-date\" id=\"birth-date\" placeholder=\"Voer uw geboortedatum in\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div>\r\n\t\t<label for=\"phone\" class=\"block mb-2\">Phone mobile*<\/label>\r\n\t\t<input type=\"tel\" name=\"phone\" id=\"phone\" placeholder=\"Vul uw telefoonnummer in\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\t<div>\r\n\t\t<label for=\"email\" class=\"block mb-2\">Email*<\/label>\r\n\t\t<input type=\"email\" name=\"email\" id=\"email\" placeholder=\"Vul uw e-mailadres in\" required=\"true\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n  \r\n   \r\n  <div class=\"lg:col-span-2\">\r\n\t\t<label for=\"referred\" class=\"block mb-2\">Referred by (your name\/practice): <\/label>\r\n\t\t<textarea name=\"referred\" id=\"referred\" placeholder=\"\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\"><\/textarea>\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2 flex flex-col space-y-2\">\r\n\t\t<h3 class=\"mt-6 mb-0\">Reason for referral (tick all that apply)<\/h3>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"General diagnosis and possible treatment\" \/> \r\n\t\t\t<span>General diagnosis and possible treatment<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Activator treatment for a large overbite or open bite (from approximately 9 years)\" \/> \r\n\t\t\t<span>Activator treatment for a large overbite or open bite (from approximately 9 years)<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Class II malocclusion\" \/> \r\n\t\t\t<span>Class II malocclusion<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Cross bite\" \/> \r\n\t\t\t<span>Cross bite<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Schaarbeet\" \/> \r\n\t\t\t<span>Schaarbeet<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Lack of space\/crowding\" \/> \r\n\t\t\t<span>Lack of space\/crowding<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Space surplus\/spacing\" \/> \r\n\t\t\t<span>Space surplus\/spacing<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Patient's own request\" \/> \r\n\t\t\t<span>Patient&#8217;s own request<\/span>\r\n\t\t<\/label>\r\n\t\t<label class=\"flex items-center\">\r\n\t\t\t<input type=\"checkbox\" class=\"mr-2 text-primary focus:ring-primary\" name=\"reason[]\" value=\"Other...(use the text field below)\" \/> \r\n\t\t\t<span>Other&#8230;(use the text box below)<\/span>\r\n\t\t<\/label>\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2\">\r\n\t\t<label for=\"other\" class=\"block mb-2\">Fill in if you have chosen \u201cother\u201d above:<\/label>\r\n\t\t<input type=\"text\" name=\"other\" id=\"other\" placeholder=\"\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\">\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2\">\r\n\t\t<label for=\"comments\" class=\"block mb-2\">Any comments and\/or remarks: <\/label>\r\n\t\t<textarea name=\"comments\" id=\"comments\" placeholder=\"\" class=\"w-full placeholder-gray-medium px-5 py-4 border-formborder focus:border-primary focus:ring-primary\"><\/textarea>\r\n\t<\/div>\r\n\r\n\t<div class=\"lg:col-span-2 text-left\">\r\n\t\t<button type=\"submit\" class=\"bg-primary-medium text-xl tracking-widest py-4 px-16 inline-flex uppercase text-white justify-center items-center font-title font-bold hover:bg-primary-dark transition duration-200 select-none\">Send Referral<\/button>\r\n\t<\/div>\r\n\r\n<\/div><noscript>Please enable JavaScript for this form to work.<\/noscript><\/div><\/form><!-- \/ HTML Forms -->","protected":false},"excerpt":{"rendered":"<p>Dear Doctor, Thank you for referring your patient to our orthodontic practice! You can use&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-simple.php","meta":{"footnotes":""},"class_list":["post-445","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.2 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Referral - Apollo<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.apollo-ortho.nl\/en\/referral\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Referral - Apollo\" \/>\n<meta property=\"og:description\" content=\"Dear Doctor, Thank you for referring your patient to our orthodontic practice! 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