{"id":2135,"date":"2024-12-29T07:12:42","date_gmt":"2024-12-29T07:12:42","guid":{"rendered":"https:\/\/smile4u.co.uk\/croydon\/?page_id=2135"},"modified":"2025-11-11T13:43:47","modified_gmt":"2025-11-11T13:43:47","slug":"ct-scan-referral","status":"publish","type":"page","link":"https:\/\/smile4u.co.uk\/dentist-croydon\/ct-scan-referral\/","title":{"rendered":"CT-Scan Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"2135\" class=\"elementor elementor-2135\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-286ce33 e-flex e-con-boxed e-con e-parent\" data-id=\"286ce33\" data-element_type=\"container\" data-e-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<div class=\"elementor-element elementor-element-94bb31c e-con-full e-flex e-con e-child\" data-id=\"94bb31c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c8b50ae elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"c8b50ae\" data-element_type=\"widget\" data-e-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\">CT-Scan Referral Form<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-491e1c2 elementor-widget-mobile__width-inherit elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"491e1c2\" data-element_type=\"widget\" data-e-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>Please fill in the form below to provide information about the CT Scan Referral.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\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<div class=\"elementor-element elementor-element-37eda019 e-flex e-con-boxed e-con e-parent\" data-id=\"37eda019\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-42b6e9d5 elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"42b6e9d5\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Patient Referral form from Alaska House Dental\" aria-label=\"Patient Referral form from Alaska House Dental\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"2135\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"42b6e9d5\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Smile 4 U &#8211; Croydon\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-firstname elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-firstname\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFirst Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[firstname]\" id=\"form-field-firstname\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Patient First Name *\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-lastname elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-lastname\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tLast Name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[lastname]\" id=\"form-field-lastname\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Patient Last Name *\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-patientemail elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientemail\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[patientemail]\" id=\"form-field-patientemail\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Patient Email *\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-patienttelephone elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patienttelephone\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTelephone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[patienttelephone]\" id=\"form-field-patienttelephone\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Patient Phone Number *\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-patientdob elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientdob\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDate of Birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[patientdob]\" id=\"form-field-patientdob\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" placeholder=\"Patient Date of Birth *\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-patientaddress elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patientaddress\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPatient Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[patientaddress]\" id=\"form-field-patientaddress\" rows=\"4\" placeholder=\"Patient Address *\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-nameofdentist elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-nameofdentist\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tName of Dentist \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[nameofdentist]\" id=\"form-field-nameofdentist\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Name of Dentist *\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-dentisttelephone elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentisttelephone\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDentist\u2019s Phone Number \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[dentisttelephone]\" id=\"form-field-dentisttelephone\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Dentist\u2019s Phone Number *\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-postcode elementor-col-50 elementor-md-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-postcode\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPractice Postcode \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[postcode]\" id=\"form-field-postcode\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Practice Postcode *\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-referringdentist elementor-col-50 elementor-md-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-referringdentist\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tReferring Dentist Email Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[referringdentist]\" id=\"form-field-referringdentist\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Referring Dentist Email Address *\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c128a99 elementor-col-100 elementor-md-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c128a99\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tReferrer GDC Number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c128a99]\" id=\"form-field-field_c128a99\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Referrer GDC Number *\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-practiceaddress elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-practiceaddress\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPractice Address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[practiceaddress]\" id=\"form-field-practiceaddress\" rows=\"4\" placeholder=\"Practice Address *\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_efb902f elementor-col-100\">\n\t\t\t\t\tConfirm Irmer Referrer Training *\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-tretmentreq elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tretmentreq\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tConfirm Irmer Referrer Training *\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-tretmentreq-0\" name=\"form_fields[tretmentreq]\"> <label for=\"form-field-tretmentreq-0\">Yes<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_11218ac elementor-col-100\">\n\t\t\t\t\tRegion to be Scanned *\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_f18a576 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f18a576\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tRegion to be Scanned\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Maxillae\" id=\"form-field-field_f18a576-0\" name=\"form_fields[field_f18a576]\" required=\"required\"> <label for=\"form-field-field_f18a576-0\">Maxillae<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Mandible\" id=\"form-field-field_f18a576-1\" name=\"form_fields[field_f18a576]\" required=\"required\"> <label for=\"form-field-field_f18a576-1\">Mandible<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Both\" id=\"form-field-field_f18a576-2\" name=\"form_fields[field_f18a576]\" required=\"required\"> <label for=\"form-field-field_f18a576-2\">Both<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-field_f18a576-3\" name=\"form_fields[field_f18a576]\" required=\"required\"> <label for=\"form-field-field_f18a576-3\">Other<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a266de8 elementor-col-100\">\n\t\t\t\t\tPatient to wear stent provided by dentist ? *\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c257749 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c257749\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPatient to wear stent provided by dentist ? *\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c257749-0\" name=\"form_fields[field_c257749]\" required=\"required\"> <label for=\"form-field-field_c257749-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c257749-1\" name=\"form_fields[field_c257749]\" required=\"required\"> <label for=\"form-field-field_c257749-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_04b4443 elementor-col-100\">\n\t\t\t\t\tDue to the many different types of radiographic stents, it is essential that you ensure that your patient is competent in positioning it to your specifications. *\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_172f4f8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_172f4f8\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tYes, patient is competent\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes, patient is competent\" id=\"form-field-field_172f4f8-0\" name=\"form_fields[field_172f4f8]\"> <label for=\"form-field-field_172f4f8-0\">Yes, patient is competent<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4dc5ebb elementor-col-100\">\n\t\t\t\t\t2nd scan, of stent, required ? *\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_5838f76 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5838f76\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t2nd scan, of stent, required ? *\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_5838f76-0\" name=\"form_fields[field_5838f76]\" required=\"required\"> <label for=\"form-field-field_5838f76-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_5838f76-1\" name=\"form_fields[field_5838f76]\" required=\"required\"> <label for=\"form-field-field_5838f76-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_b74aa0e elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b74aa0e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tReason for Referral and Justification for the scan\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_b74aa0e]\" id=\"form-field-field_b74aa0e\" rows=\"4\" placeholder=\"Reason for Referral and Justification for the scan *\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_1ce1e77 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1ce1e77\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSpecial Instructions to IRMER operator involved in scan acquisition\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_1ce1e77]\" id=\"form-field-field_1ce1e77\" rows=\"4\" placeholder=\"Special Instructions to IRMER operator involved in scan acquisition *\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_193f005 elementor-col-100\">\n\t\t\t\t\tConfirm image only *\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_35347bc elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_35347bc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tConfirm image only *\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_35347bc-0\" name=\"form_fields[field_35347bc]\" required=\"required\"> <label for=\"form-field-field_35347bc-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_35347bc-1\" name=\"form_fields[field_35347bc]\" required=\"required\"> <label for=\"form-field-field_35347bc-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_164c3fc elementor-col-100\">\n\t\t\t\t\tRadiologist report needed *\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_ad22e2f elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ad22e2f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tRadiologist report needed\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_ad22e2f-0\" name=\"form_fields[field_ad22e2f]\" required=\"required\"> <label for=\"form-field-field_ad22e2f-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_ad22e2f-1\" name=\"form_fields[field_ad22e2f]\" required=\"required\"> <label for=\"form-field-field_ad22e2f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_58145db elementor-col-100\">\n\t\t\t\t\tTreatment Costs *\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ac42e6a elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ac42e6a\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTreatment Costs *\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Dental CT Scan for single tooth or jaw : \u00a3___\" id=\"form-field-field_ac42e6a-0\" name=\"form_fields[field_ac42e6a][]\"> <label for=\"form-field-field_ac42e6a-0\">Dental CT Scan for single tooth or jaw : \u00a3___<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Dental CT Scan for both jaws : \u00a3___\" id=\"form-field-field_ac42e6a-1\" name=\"form_fields[field_ac42e6a][]\"> <label for=\"form-field-field_ac42e6a-1\">Dental CT Scan for both jaws : \u00a3___<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Second scan of stent for \u201cNobelguide\u201d or similar : \u00a3___\" id=\"form-field-field_ac42e6a-2\" name=\"form_fields[field_ac42e6a][]\"> <label for=\"form-field-field_ac42e6a-2\">Second scan of stent for \u201cNobelguide\u201d or similar : \u00a3___<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Radiologist report, where requested, shall be quoted separately.\" id=\"form-field-field_ac42e6a-3\" name=\"form_fields[field_ac42e6a][]\"> <label for=\"form-field-field_ac42e6a-3\">Radiologist report, where requested, shall be quoted separately.<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e868b39 elementor-col-100\">\n\t\t\t\t\t<b> NOTE<\/b> : CT-Scan files will be given to the patient on a CD with the required viewing software.\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_3f426a5 elementor-col-100\">\n\t\t\t\t\tAcceptance *\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_8e03690 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8e03690\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tI consent to my data being used in accordance to the Privacy Policy. \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_8e03690]\" id=\"form-field-field_8e03690\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_8e03690\">I consent to my data being used in accordance to the <a style=\"color:#4E4E4E\" href=\"https:\/\/smile4u.co.uk\/croydon\/privacy-policy\/\" target=\"_blank\">Privacy Policy.<\/a><\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha elementor-field-group elementor-column elementor-field-group-field_e193ced elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_e193ced\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LeOSFsrAAAAADxDoDIpWWQzpYr1mwS4RG5ZRogp\" data-type=\"v2_checkbox\" data-theme=\"light\" 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Referral.<\/p>\n","protected":false},"author":1,"featured_media":2128,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"","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":"","ast-disable-related-posts":"","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":"default","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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