{"id":13289,"date":"2023-04-11T07:58:46","date_gmt":"2023-04-11T07:58:46","guid":{"rendered":"https:\/\/sylvainchamberland.com\/?page_id=13289"},"modified":"2023-08-21T12:45:08","modified_gmt":"2023-08-21T12:45:08","slug":"referral-by-the-dentist","status":"publish","type":"page","link":"https:\/\/www.sylvainchamberland.com\/en\/referral-by-the-dentist\/","title":{"rendered":"Referral by the dentist"},"content":{"rendered":"\t\t<script src=\"https:\/\/www.sylvainchamberland.com\/wp-content\/plugins\/wp-plogg-patient-referral\/includes\/assets\/js\/dropzone.js\"><\/script>\r\n\t\t<script src=\"https:\/\/www.sylvainchamberland.com\/wp-content\/plugins\/wp-plogg-patient-referral\/includes\/assets\/js\/moment.min.js\"><\/script>\r\n\t\t\t\t\t<script src='https:\/\/www.google.com\/recaptcha\/api.js'><\/script>\r\n\t\t\t\t<div id=\"wp-plogg-patient-referral-div\">\r\n\t\t\t<div class=\"wrapper\">\r\n\t\r\n\t\t\t\t<div id=\"container\" class=\"\">\r\n\t\t\t\t\t<div id=\"content\" role=\"main\">\r\n\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t<link rel=\"stylesheet\" href=\"\/\/ajax.googleapis.com\/ajax\/libs\/jqueryui\/1.11.2\/themes\/smoothness\/jquery-ui.css\" property=\"\"\/>\r\n\t\t\t\t\t\t<script src=\"\/\/ajax.googleapis.com\/ajax\/libs\/jqueryui\/1.11.2\/jquery-ui.min.js\"><\/script>\r\n\t\t\t\t\t\t<script>\r\n\t\t\t\t\t\t\t$(document).ready(function(){\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t$( \".datepicker\" ).datepicker({\r\n\t\t\t\t\t\t\t\t\tdateFormat: 'yy-mm-dd',\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tyearRange: \"-90:+1\",\r\n\t\t\t\t\t\t\t\t\t\tchangeYear: true,\r\n\t\t\t\t\t\t\t\t\t\tdefaultDate:\"-20Y\"\r\n\t\t\t\t\t\t\t\t});\r\n\t\t\t\t\t\t\t});\r\n\t\t\t\t\t\t<\/script>\r\n\r\n\t\t\t\t\t\t<div class=\"content-wrapper\">\r\n\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t<div class=\"form-wrapper\">\r\n\t\t\t\t\t\t\t\t<form action=\"https:\/\/www.sylvainchamberland.com\/wp-content\/plugins\/wp-plogg-patient-referral\/includes\/form-manager.php\" method=\"post\" id=\"contact-form\" enctype=\"multipart\/form-data\">\r\n\t\t\t\t\t\t\t\t\t<input type=\"hidden\" name=\"wp_plogg_patient_referral_nomformulaire\"  id=\"wp_plogg_patient_referral_nomformulaire\" value=\"refererpatient\"\/>\r\n\t\t\t\t\t\t\t\t\t<input type=\"hidden\" name=\"wp_plogg_patient_referral_goto\"  id=\"wp_plogg_patient_referral_goto\" value=\"https:\/\/www.sylvainchamberland.com\/en\/referral-by-the-dentist\/\"\/>\r\n\t\t\t\t\t\t\t\t\t<input type=\"text\" name=\"wp_plogg_patient_referral_magicfield\"  class=\"wp_plogg_patient_referral_magicfield\" value=\"\" autocomplete=\"off\"\/>\r\n\t\t\t\t\t\t\t\t\t<input type=\"hidden\" name=\"wp_plogg_patient_referral_lang\"  id=\"wp_plogg_patient_referral_lang\" value=\"en\"\/>\r\n\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t<div class=\"line half-col-wrapper first-line-wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t<div class=\"col-left-60\">\r\n\t\t\t\t\t\t\t\t\t\t\t<h2>Patient<\/h2>\r\n\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"half-col-wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"half-left\">\r\n\t\t\t\t\t\t\t\t\t\t\t  \t\t<input type=\"radio\" name=\"sexe\" id=\"homme\" value=\"homme\" class=\"custom-radio\" checked \/><label for=\"homme\">Male<\/label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"half-rigth\">\r\n\t\t\t\t\t\t\t\t\t\t\t  \t\t<input type=\"radio\" name=\"sexe\" id=\"femme\" value=\"femme\" class=\"custom-radio\" \/><label for=\"femme\">Female<\/label>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"half-col-wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"text\" name=\"prenom\" id=\"prenom\" placeholder=\"First name *\" required\/>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"text\" name=\"nom\" id=\"nom\" placeholder=\"Last name *\" required\/>\r\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\r\n\t\t\t\t\t\t\t\t\t\t\t<label>Birth date<\/label><br\/>\r\n                                            <div class=\"half-col-wrapper date_naissance\">\r\n                                                <input type=\"number\" name=\"datenaissance_day\" id=\"datenaissance_day\" min=\"1\" max=\"31\" placeholder=\"Day *\" autocomplete=\"off\" required>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"datenaissance_month\" id=\"datenaissance_month\" min=\"1\" max=\"12\" placeholder=\"Month *\" autocomplete=\"off\" required>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"datenaissance_year\" id=\"datenaissance_year\" min=\"1900\" max=\"2026\" placeholder=\"Year *\" autocomplete=\"off\" required>\r\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\r\n                                            <div class=\"half-col-wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"text\" name=\"tel\" id=\"tel\" placeholder=\"Phone *\" required\/>\r\n                                                <input type=\"email\" name=\"email\" id=\"email\" placeholder=\"Email \" \/>\r\n                                            <\/div>\r\n\r\n\t\t\t\t\t\t\t\t\t\t\t<div class=\"half-col-wrapper\">\r\n                                                <input type=\"text\" name=\"adresse\" id=\"adresse\" placeholder=\"Address *\" required\/>\r\n                                            <\/div>\r\n\r\n                                            <div class=\"half-col-wrapper\">\r\n                                            \t<input type=\"text\" name=\"ville\" id=\"ville\" placeholder=\"Town *\" required>\r\n                                                <input type=\"text\" name=\"postal_code\" id=\"postal_code\" placeholder=\"Postal code *\" required\/>\r\n                                            <\/div>\t\t\t\t\t\t\t\t\t\t  \t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t<\/div>\r\n                                        <div class=\"col-right-40\">\r\n                                           \r\n\r\n\t\t\t\t\t\t\t\t\t\t\t<h2>Reason for consultation<\/h2>\r\n\r\n                                            <div class=\"half-col-wrapper\">\r\n                                                \r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_1\" value=\"Congenital absence\" class=\"custom-radio\" required checked\/><label for=\"reason_consultation_1\">Congenital absence<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_2\" value=\"Crossed joint\" class=\"custom-radio\"\/><label for=\"reason_consultation_2\">Crossed joint<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_3\" value=\"Class II\" class=\"custom-radio\"\/><label for=\"reason_consultation_3\">Class II<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_4\" value=\"Class III\" class=\"custom-radio\"\/><label for=\"reason_consultation_4\">Class III<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_5\" value=\"Lack of space\" class=\"custom-radio\"\/><label for=\"reason_consultation_5\">Lack of space<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_6\" value=\"Diastema\" class=\"custom-radio\"\/><label for=\"reason_consultation_6\">Diastema<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_7\" value=\"Tooth included\" class=\"custom-radio\"\/><label for=\"reason_consultation_7\">Tooth included<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_9\" value=\"ATM problem\" class=\"custom-radio\"\/><label for=\"reason_consultation_9\">ATM problem<\/label><br\/>\r\n\r\n                                                <input type=\"radio\" name=\"reason_consultation\" id=\"reason_consultation_11\" value=\"Other\" class=\"custom-radio\"\/><label for=\"reason_consultation_11\">Other<\/label><br\/>\r\n\r\n                                            <\/div>\r\n\t\t\t\t\t\t\t\t\t\t\t<br\/>\r\n\r\n                                        \t<h2>Additional information<\/h2>\r\n\r\n                                        \t<textarea name=\"infos_comp\" id=\"infos_comp\"  placeholder=\"Enter more details here\"><\/textarea>\r\n\r\n\r\n                                        <\/div>\r\n\r\n\t\t\t\t\t\t\t\t\t<\/div>\r\n\r\n                                    <div class=\"line half-col-wrapper\">\r\n\r\n                                    \t<br\/>\r\n\r\n                                    \t<div class=\"col-left\">\r\n\r\n                                        \t<h2>Referent<\/h2>\r\n\r\n                                        \t<input type=\"text\" name=\"recommande\" id=\"recommande\" placeholder=\"Dentist Name *\" required\/>\r\n\r\n                                        \t<input type=\"text\" name=\"no_pratique\" id=\"no_pratique\" placeholder=\"Practice number *\" required\/>\r\n\r\n                                        \t<input type=\"text\" name=\"phone_referent\" id=\"phone_referent\" placeholder=\"Phone *\" required\/>\r\n\r\n                                        \t<input type=\"email\" name=\"courriel_dentiste\" id=\"courriel_dentiste\" placeholder=\"Email *\"  required\/>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<p>This email will be used to send you a confirmation and \/ or consultation report.<\/p>\r\n\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\r\n                                        <div class=\"col-right\">\r\n\r\n                                        \t<h2>Attach x-rays or photos<\/h2>\r\n                                        \t\r\n                                        \t<label for=\"addFiles\">Are there any images attached to this form?<br><\/label>\r\n                                        \t\r\n                                        \t<input type=\"radio\" name=\"addFiles\" id=\"addFilesOui\" value=\"oui\" checked=\"true\" class=\"custom-radio\"\/>\r\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"addFilesOui\"><strong>Yes<\/strong><\/label>\r\n                                        \t\r\n                                        \t<input type=\"radio\" name=\"addFiles\" id=\"addFilesNon\" value=\"non\" class=\"custom-radio\"\/>\r\n\t\t\t\t\t\t\t\t\t\t\t<label for=\"addFilesNon\"><strong>No<\/strong><\/label>\r\n                                        \t\r\n                                        \t<div id=\"radio-container\">\r\n\r\n\t                                        \t<h4>Photos: (10 maximum)<br\/>-X-ray(s)<br\/>-Photo(s)<\/h4>\r\n\t\t\t\t\t\t\t\t\t\t  \t\t\t\t\t\t\t\t\t\t\t\t\t\t<div id=\"file\" class=\"dropzone\"><\/div>\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t<p class=\"field-comment\">Formats jpg, pdf, txt, 4 mega-bytes maximum each<\/p>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t<input type=\"text\" autocomplete=\"off\" class=\"datepicker\" name=\"date_radio\" id=\"date_radio\" placeholder=\"X-ray date \" required\/>\r\n\t\t\t\t\t\t\t\t\t\t\t\t<p>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\tYou are not into digital? Nothing more simple, take a photo of your radiography with a smartphone and send it to you by email. Then download this image on your computer. From this form, select the image. Repeat this process for all your X-rays and photographs.\t\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\r\n                                        \t<\/div>\r\n\r\n                                        <\/div>\r\n\r\n                                    <\/div>\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t<div class=\"form-bottom-wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t<div class=\"line soins-wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t<div class=\"bottom-wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t<br\/>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"g-recaptcha\" id=\"g-recaptcha\" data-sitekey=\"6LdlneEaAAAAAAysc6WI8gr2gqltnbcrHr2cNykX\"><\/div>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<p>Fields marked with an asterisk (*) are required.<\/p>\r\n\t\t\t\t\t\t\t\t\t\t<button type=\"submit\" class=\"button\" name=\"submit\">Send<\/button>\r\n\t\t\t\t\t\t\t\t\t<\/div>\r\n\t\t\t\t\t\t\t\t<\/form>\r\n\t\t\t\t\t\t\t\t<script>\r\n                                    $('#raison_urgence').slideUp();\r\n\t\t\t\t\t\t\t\t\t$('input[type=radio][name=emergency]').change(function() {\r\n\t\t\t\t\t\t\t\t\t    if (this.value == 'urgent') {\r\n\t\t\t\t\t\t\t\t\t        $('#raison_urgence').slideDown();\r\n\t\t\t\t\t\t\t\t\t        $(\"#raison_urgence\").prop('required',true);\r\n\t\t\t\t\t\t\t\t\t    }\r\n\t\t\t\t\t\t\t\t\t    else {\r\n\t\t\t\t\t\t\t\t\t        $('#raison_urgence').slideUp();\r\n\t\t\t\t\t\t\t\t\t        $(\"#raison_urgence\").prop('required',false);\r\n\t\t\t\t\t\t\t\t\t    }\r\n\t\t\t\t\t\t\t\t\t});\r\n\r\n                                    $('input[type=radio][name=addFiles]').change(function () {\r\n                                        if (this.value == 'oui') {\r\n                                            $('#radio-container').slideDown();\r\n                                            $(\"#date_radio\").prop('required', true);\r\n                                        } else if (this.value == 'non') {\r\n                                            $('#radio-container').slideUp();\r\n                                            $(\"#date_radio\").prop('required', false);\r\n                                        }\r\n\r\n                                    });\r\n\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\/\/ @see: https:\/\/github.com\/enyo\/dropzone\/wiki\/Combine-normal-form-with-Dropzone\r\n\t\t\t\t\t\t\t\t\t\/\/ Disabling autoDiscover, otherwise Dropzone will try to attach twice.\r\n\t\t\t\t\t\t\t\t\tDropzone.autoDiscover = false;\r\n\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t$(document).ready(function(){\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\/\/ or disable for specific dropzone:\r\n\t\t\t\t\t\t\t\t\t\t\/\/ Dropzone.options.myDropzone = false;\r\n\t\t\t\t\t\t\t\t\t\tDropzone.options.file = { \/\/ The camelized version of the ID of the form element\r\n\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t  \/\/ The configuration we've talked about above\r\n\t\t\t\t\t\t\t\t\t\t  url: 'https:\/\/www.sylvainchamberland.com\/wp-content\/plugins\/wp-plogg-patient-referral\/includes\/form-manager.php',\r\n\t\t\t\t\t\t\t\t\t\t  autoProcessQueue: false,\r\n\t\t\t\t\t\t\t\t\t\t  uploadMultiple: true,\r\n\t\t\t\t\t\t\t\t\t\t  parallelUploads: 100,\r\n\t\t\t\t\t\t\t\t\t\t  maxFiles: 10,\r\n\t\t\t\t\t\t\t\t\t\t  maxFilesize: 4,\r\n\t\t\t\t\t\t\t\t\t\t  addRemoveLinks: true,\r\n\t\t\t\t\t\t\t\t\t\t  renameFilename: function (filename) {\r\n\t\t\t\t\t\t\t\t\t\t  \t\treturn filename;\r\n\t\t\t\t\t\t\t\t          },\r\n\t\t\t\t\t\t\t\t          dictDefaultMessage: \"Drop files here to upload\",\r\n\t\t\t\t\t\t\t\t          dictMaxFilesExceeded: \"You can not upload any more files.\",\r\n\t\t\t\t\t\t\t\t          dictRemoveFile: \"Remove file\",\r\n\t\t\t\t\t\t\t\t\t\t  \/\/ The setting up of the dropzone\r\n\t\t\t\t\t\t\t\t\t\t  init: function() {\r\n\t\t\t\t\t\t\t\t\t\t    var dropZonePrincipal = this;\r\n\t\t\t\t\t\t\t\t\t\t    var submitButton = $(\"#contact-form button[type=submit]\");\r\n\t\t\t\t\t\t\t\t\t\t    \r\n\t\t\t\t\t\t\t\t\t\t    \/\/ First change the button to actually tell Dropzone to process the queue.\r\n\t\t\t\t\t\t\t\t\t\t    $('#contact-form').on(\"submit\", function(e) {\r\n\t\t\t\t\t\t\t\t\t\t\t\tlocalStorage.removeItem('return_form');\r\n\r\n\t\t\t\t\t\t\t\t\t\t\t\tif(!wp_plogg_patient_referral_validation()){\r\n\t\t\t\t\t\t\t\t\t\t\t\t\treturn false;\r\n\t\t\t\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t    if($('#contact-form')[0].checkValidity()){\r\n\t\t\t\t\t\t\t\t\t\t\t\t    var total_pictures_upload = dropZonePrincipal.getQueuedFiles().length;\r\n\t\t\t\t\t\t\t\t\t\t\t\t\tif(total_pictures_upload >\u00a00 ){\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\te.preventDefault();\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t    \t\t$('html').addClass('loading');\r\n\t\t\t\t\t\t\t\t\t\t\t    \t\t$(\"html, body\").animate({ scrollTop: 0 }, \"slow\");\r\n\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t\t    \t\/\/var total_pictures_upload = dropZonePrincipal.getQueuedFiles().length;\r\n\t\t\t\t\t\t\t\t\t\t\t\t    \t\/\/console.log(total_pictures_upload);\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\tconsole.log(\"in dropzone\");\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/\/if (total_pictures_upload >\u00a00) {\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/\/ Make sure that the form isn't actually being sent.\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\tdropZonePrincipal.processQueue();\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\/\/}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t}else if($('input[name=addFiles]:checked', '#contact-form').val() == \"oui\"){\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\talert('Attach x-rays or photos');\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\treturn false;\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t$('html').addClass('loading');\r\n\t\t\t\t\t\t\t\t\t\t\t    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