{"id":3528,"date":"2024-01-17T10:00:33","date_gmt":"2024-01-17T10:00:33","guid":{"rendered":"https:\/\/endo-zuerich.ch\/?page_id=3528"},"modified":"2024-10-31T08:33:25","modified_gmt":"2024-10-31T08:33:25","slug":"online-ueberweisung","status":"publish","type":"page","link":"https:\/\/endo-zuerich.ch\/en\/online-ueberweisung\/","title":{"rendered":"Referral form"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row row_height_percent=&#8221;0&#8243; override_padding=&#8221;yes&#8221; h_padding=&#8221;2&#8243; top_padding=&#8221;3&#8243; bottom_padding=&#8221;3&#8243; overlay_alpha=&#8221;50&#8243; gutter_size=&#8221;3&#8243; column_width_percent=&#8221;100&#8243; shift_y=&#8221;0&#8243; z_index=&#8221;0&#8243; uncode_shortcode_id=&#8221;166988&#8243;][vc_column column_width_percent=&#8221;100&#8243; gutter_size=&#8221;4&#8243; overlay_alpha=&#8221;50&#8243; shift_x=&#8221;0&#8243; shift_y=&#8221;0&#8243; shift_y_down=&#8221;0&#8243; z_index=&#8221;0&#8243; medium_width=&#8221;0&#8243; mobile_width=&#8221;0&#8243; width=&#8221;1\/1&#8243; uncode_shortcode_id=&#8221;787600&#8243;][vc_custom_heading auto_text=&#8221;yes&#8221; text_size=&#8221;&#8221; uncode_shortcode_id=&#8221;182086&#8243;][\/vc_custom_heading]<div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-3868\"><form id=\"wpforms-form-3868\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"3868\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/3528\" data-token=\"d07274429df8ed80c40170a98145afad\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-3868-field_13-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"13\"><h3 id=\"wpforms-3868-field_13\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-3868-field_13-error\">Practice<\/h3><\/div><div id=\"wpforms-3868-field_9-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-first\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_9\">Medical practice<\/label><input type=\"text\" id=\"wpforms-3868-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-3868-field_9-error\" ><\/div><div id=\"wpforms-3868-field_14-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_14\">Dentist<\/label><input type=\"text\" id=\"wpforms-3868-field_14\" class=\"wpforms-field-large\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-3868-field_14-error\" ><\/div><div id=\"wpforms-3868-field_52-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_52\">Street, no.<\/label><input type=\"text\" id=\"wpforms-3868-field_52\" class=\"wpforms-field-large\" name=\"wpforms[fields][52]\" aria-errormessage=\"wpforms-3868-field_52-error\" ><\/div><div id=\"wpforms-3868-field_11-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_11\">Phone<\/label><input type=\"tel\" id=\"wpforms-3868-field_11\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-3868-field_11-error\" ><\/div><div id=\"wpforms-3868-field_53-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_53\">ZIP code, city<\/label><input type=\"text\" id=\"wpforms-3868-field_53\" class=\"wpforms-field-large\" name=\"wpforms[fields][53]\" aria-errormessage=\"wpforms-3868-field_53-error\" ><\/div><div id=\"wpforms-3868-field_10-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_10\">E-mail<\/label><input type=\"email\" id=\"wpforms-3868-field_10\" class=\"wpforms-field-large\" name=\"wpforms[fields][10]\" spellcheck=\"false\" aria-errormessage=\"wpforms-3868-field_10-error\" ><\/div><div id=\"wpforms-3868-field_16-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"16\"><h3 id=\"wpforms-3868-field_16\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-3868-field_16-error\">Patient<\/h3><\/div><div id=\"wpforms-3868-field_71-container\" class=\"wpforms-field wpforms-field-name wpforms-one-half wpforms-first\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_71\">Surname, first name<\/label><input type=\"text\" id=\"wpforms-3868-field_71\" class=\"wpforms-field-large\" name=\"wpforms[fields][71]\" aria-errormessage=\"wpforms-3868-field_71-error\" ><\/div><div id=\"wpforms-3868-field_61-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label\">Date of birth<\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-small\"><select name=\"wpforms[fields][61][date][d]\" id=\"wpforms-3868-field_61-day\" class=\"wpforms-field-date-time-date-day\" aria-label=\"Day\" ><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][61][date][m]\" id=\"wpforms-3868-field_61-month\" class=\"wpforms-field-date-time-date-month\" aria-label=\"Month\" ><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][61][date][y]\" id=\"wpforms-3868-field_61-year\" class=\"wpforms-field-date-time-date-year\" aria-label=\"Year\" ><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><div id=\"wpforms-3868-field_55-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_55\">Street, no.<\/label><input type=\"text\" id=\"wpforms-3868-field_55\" class=\"wpforms-field-large\" name=\"wpforms[fields][55]\" aria-errormessage=\"wpforms-3868-field_55-error\" ><\/div><div id=\"wpforms-3868-field_19-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_19\">Phone<\/label><input type=\"tel\" id=\"wpforms-3868-field_19\" class=\"wpforms-field-large wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][19]\" aria-errormessage=\"wpforms-3868-field_19-error\" ><\/div><div id=\"wpforms-3868-field_56-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_56\">ZIP code, city<\/label><input type=\"text\" id=\"wpforms-3868-field_56\" class=\"wpforms-field-large\" name=\"wpforms[fields][56]\" aria-errormessage=\"wpforms-3868-field_56-error\" ><\/div><div id=\"wpforms-3868-field_20-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_20\">E-mail<\/label><input type=\"email\" id=\"wpforms-3868-field_20\" class=\"wpforms-field-large\" name=\"wpforms[fields][20]\" spellcheck=\"false\" aria-errormessage=\"wpforms-3868-field_20-error\" ><\/div><div id=\"wpforms-3868-field_96-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"96\"><fieldset><legend class=\"wpforms-field-label\">Coverage<\/legend><ul id=\"wpforms-3868-field_96\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_96_1\" name=\"wpforms[fields][96]\" value=\"Self-coverage\" aria-errormessage=\"wpforms-3868-field_96_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_96_1\">Self-coverage<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_96_2\" name=\"wpforms[fields][96]\" value=\"Insurance (Accident, UVG \/ Disability, IV  \/ Military, MV)\" aria-errormessage=\"wpforms-3868-field_96_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_96_2\">Insurance (Accident, UVG \/ Disability, IV  \/ Military, MV)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_96_3\" name=\"wpforms[fields][96]\" value=\"Basic Health Insurance (KVG)\" aria-errormessage=\"wpforms-3868-field_96_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_96_3\">Basic Health Insurance (KVG)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_96_5\" name=\"wpforms[fields][96]\" value=\"Supplementary Benefits (to AHV\/IV)\" aria-errormessage=\"wpforms-3868-field_96_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_96_5\">Supplementary Benefits (to AHV\/IV)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_96_6\" name=\"wpforms[fields][96]\" value=\"Other:\" aria-errormessage=\"wpforms-3868-field_96_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_96_6\">Other:<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-3868-field_97-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-3868-field_97\" aria-hidden=\"false\">Other <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-3868-field_97\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][97]\" aria-errormessage=\"wpforms-3868-field_97-error\" required><\/div><div id=\"wpforms-3868-field_21-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"21\"><h3 id=\"wpforms-3868-field_21\" name=\"wpforms[fields][21]\" aria-errormessage=\"wpforms-3868-field_21-error\">Desired treatment<\/h3><\/div><div id=\"wpforms-3868-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_29\">Tooth\/Teeth\/Region<\/label><input type=\"text\" id=\"wpforms-3868-field_29\" class=\"wpforms-field-large\" name=\"wpforms[fields][29]\" placeholder=\"e.g. tooth 36, region 24 - 27\" aria-errormessage=\"wpforms-3868-field_29-error\" ><\/div><div id=\"wpforms-3868-field_24-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns wpforms-conditional-trigger\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Transfer for<\/legend><ul id=\"wpforms-3868-field_24\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_24_4\" name=\"wpforms[fields][24][]\" value=\"Diagnostics\/consulting\" aria-errormessage=\"wpforms-3868-field_24_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_24_4\">Diagnostics\/consulting<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_24_3\" name=\"wpforms[fields][24][]\" value=\"Microsurgical apicoectomy\" aria-errormessage=\"wpforms-3868-field_24_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_24_3\">Microsurgical apicoectomy<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_24_1\" name=\"wpforms[fields][24][]\" value=\"Root canal treatment\" aria-errormessage=\"wpforms-3868-field_24_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_24_1\">Root canal treatment<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_24_5\" name=\"wpforms[fields][24][]\" value=\"3D imaging (DVT)\" aria-errormessage=\"wpforms-3868-field_24_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_24_5\">3D imaging (DVT)<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_24_2\" name=\"wpforms[fields][24][]\" value=\"Root canal treatment revision\" aria-errormessage=\"wpforms-3868-field_24_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_24_2\">Root canal treatment revision<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_24_6\" name=\"wpforms[fields][24][]\" value=\"Other therapies\" aria-errormessage=\"wpforms-3868-field_24_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_24_6\">Other therapies<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-3868-field_73-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"73\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_73\">Other therapies<\/label><input type=\"text\" id=\"wpforms-3868-field_73\" class=\"wpforms-field-large\" name=\"wpforms[fields][73]\" placeholder=\"e.g. treatment resorption, pulpotomy, etc.\" aria-errormessage=\"wpforms-3868-field_73-error\" ><\/div><div id=\"wpforms-3868-field_40-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_40\">Comment on the treatment<\/label><textarea id=\"wpforms-3868-field_40\" class=\"wpforms-field-small\" name=\"wpforms[fields][40]\" placeholder=\"e.g. channels cannot be found, instrument removed, etc.\" aria-errormessage=\"wpforms-3868-field_40-error\" ><\/textarea><\/div><div id=\"wpforms-3868-field_87-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first\" data-field-id=\"87\"><fieldset><legend class=\"wpforms-field-label\">Need for treatment <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-3868-field_87\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-3868-field_87_1\" name=\"wpforms[fields][87]\" value=\"Normal\" aria-errormessage=\"wpforms-3868-field_87_1-error\" aria-describedby=\"wpforms-3868-field_87-description\" required  checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_87_1\">Normal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_87_2\" name=\"wpforms[fields][87]\" value=\"Urgent*\" aria-errormessage=\"wpforms-3868-field_87_2-error\" aria-describedby=\"wpforms-3868-field_87-description\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_87_2\">Urgent*<\/label><\/li><\/ul><div id=\"wpforms-3868-field_87-description\" class=\"wpforms-field-description\">*In case of high acute\/emergency please also contact us by phone.<\/div><\/fieldset><\/div><div id=\"wpforms-3868-field_88-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half\" data-field-id=\"88\"><fieldset><legend class=\"wpforms-field-label\">Would you like a phone consultation before starting treatment?<\/legend><ul id=\"wpforms-3868-field_88\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_88_1\" name=\"wpforms[fields][88]\" value=\"Yes\" aria-errormessage=\"wpforms-3868-field_88_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_88_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-3868-field_88_2\" name=\"wpforms[fields][88]\" value=\"No\" aria-errormessage=\"wpforms-3868-field_88_2-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_88_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-3868-field_63-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"63\"><h3 id=\"wpforms-3868-field_63\" name=\"wpforms[fields][63]\" aria-errormessage=\"wpforms-3868-field_63-error\">Post-endodontic care<\/h3><\/div><div id=\"wpforms-3868-field_89-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first\" data-field-id=\"89\"><fieldset><legend class=\"wpforms-field-label\">Access cavity closure<\/legend><ul id=\"wpforms-3868-field_89\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-3868-field_89_1\" name=\"wpforms[fields][89]\" value=\"Situational, when appropriate\" aria-errormessage=\"wpforms-3868-field_89_1-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_89_1\">Situational, when appropriate<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_89_2\" name=\"wpforms[fields][89]\" value=\"Definitive adhesive closure\" aria-errormessage=\"wpforms-3868-field_89_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_89_2\">Definitive adhesive closure<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_89_3\" name=\"wpforms[fields][89]\" value=\"Temporary closure\" aria-errormessage=\"wpforms-3868-field_89_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_89_3\">Temporary closure<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-3868-field_42-container\" class=\"wpforms-field wpforms-field-textarea wpforms-one-half\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-3868-field_42\">Remarks on post-endodontic treatment<\/label><textarea id=\"wpforms-3868-field_42\" class=\"wpforms-field-medium\" name=\"wpforms[fields][42]\" placeholder=\"e.g. remove crown, replace existing filling, etc.\" aria-errormessage=\"wpforms-3868-field_42-error\" ><\/textarea><\/div><div id=\"wpforms-3868-field_90-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"90\"><fieldset><legend class=\"wpforms-field-label\">Root post insertion<\/legend><ul id=\"wpforms-3868-field_90\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_90_1\" name=\"wpforms[fields][90]\" value=\"Yes\" aria-errormessage=\"wpforms-3868-field_90_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_90_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-3868-field_90_2\" name=\"wpforms[fields][90]\" value=\"No\" aria-errormessage=\"wpforms-3868-field_90_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_90_2\">No<\/label><\/li><li class=\"choice-3 depth-1 wpforms-selected\"><input type=\"radio\" id=\"wpforms-3868-field_90_3\" name=\"wpforms[fields][90]\" value=\"Yes, when appropriate\" aria-errormessage=\"wpforms-3868-field_90_3-error\"   checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_90_3\">Yes, when appropriate<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-3868-field_65-container\" class=\"wpforms-field wpforms-field-divider description-large\" data-field-id=\"65\"><h3 id=\"wpforms-3868-field_65\" name=\"wpforms[fields][65]\" aria-errormessage=\"wpforms-3868-field_65-error\" aria-describedby=\"wpforms-3868-field_65-description\">Transmission of enclosures<\/h3><div id=\"wpforms-3868-field_65-description\" class=\"wpforms-field-description\">For data protection reasons, please send all enclosures, X-ray images etc. via <a href=\"mailto:endo-zuerich@sso-hin.ch\">endo-zuerich@sso-hin.ch<\/a>.<\/div><\/div><div id=\"wpforms-3868-field_43-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"43\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Transmission of enclosures <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-3868-field_43\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_43_1\" name=\"wpforms[fields][43][]\" value=\"by encrypted e-mail\" aria-errormessage=\"wpforms-3868-field_43_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_43_1\">by encrypted e-mail<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_43_3\" name=\"wpforms[fields][43][]\" value=\"with patient\" aria-errormessage=\"wpforms-3868-field_43_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_43_3\">with patient<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_43_4\" name=\"wpforms[fields][43][]\" value=\"no enclosures available\" aria-errormessage=\"wpforms-3868-field_43_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_43_4\">no enclosures available<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-3868-field_94-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"94\"><\/div><div id=\"wpforms-3868-field_72-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"72\"><fieldset><legend class=\"wpforms-field-label wpforms-label-hide\" aria-hidden=\"false\">Consent for sending forms <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-3868-field_72\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-3868-field_72_1\" name=\"wpforms[fields][72][]\" value=\"I accept the &lt;a target=&quot;_blank&quot; href=&quot;\/impressum-datenschutz&quot;&gt;privacy policy&lt;\/a&gt; and agree that the data entered will be used for processing and sent as an e-mail confirmation.\" aria-errormessage=\"wpforms-3868-field_72_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-3868-field_72_1\">I accept the <a target=\"_blank\" href=\"\/impressum-datenschutz\">privacy policy<\/a> and agree that the data entered will be used for processing and sent as an e-mail confirmation.<\/label><\/li><\/ul><\/fieldset><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"3868\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-3868\" class=\"wpforms-submit btn btn-default\" data-alt-text=\"Send...\" data-submit-text=\"Send\" aria-live=\"assertive\" value=\"wpforms-submit\">Send<\/button><img decoding=\"async\" src=\"https:\/\/endo-zuerich.ch\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->[\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>Does your patient need endodontic treatment, endodontic therapy, or endodontic care? Refer them via our online form with all the necessary information.<\/p>\n","protected":false},"author":1,"featured_media":4096,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-3528","page","type-page","status-publish","has-post-thumbnail","hentry"],"_links":{"self":[{"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/pages\/3528","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/comments?post=3528"}],"version-history":[{"count":17,"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/pages\/3528\/revisions"}],"predecessor-version":[{"id":4332,"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/pages\/3528\/revisions\/4332"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/media\/4096"}],"wp:attachment":[{"href":"https:\/\/endo-zuerich.ch\/en\/wp-json\/wp\/v2\/media?parent=3528"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}