{"id":4133,"date":"2022-11-29T19:21:33","date_gmt":"2022-11-29T19:21:33","guid":{"rendered":"https:\/\/drpeterfritz.com\/?page_id=4133"},"modified":"2022-12-20T21:02:28","modified_gmt":"2022-12-20T21:02:28","slug":"online-referral-form","status":"publish","type":"page","link":"https:\/\/drpeterfritz.com\/online-referral-form\/","title":{"rendered":"Online Referral Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"4133\" class=\"elementor elementor-4133\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ee5391c elementor-section-full_width elementor-section-content-middle elementor-section-height-default elementor-section-height-default\" data-id=\"ee5391c\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-5eac7b4c\" data-id=\"5eac7b4c\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1262e536 elementor-widget elementor-widget-heading\" data-id=\"1262e536\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Online Referral Form<\/h1>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-4fa541b\" data-id=\"4fa541b\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-583dbba6 elementor-widget elementor-widget-heading\" data-id=\"583dbba6\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">For dental offices and prospective patients<\/h4>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6ed13a2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6ed13a2\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7ae646a\" data-id=\"7ae646a\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e7ea755 elementor-widget elementor-widget-text-editor\" data-id=\"e7ea755\" data-element_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<p>A PDF version of this form can be downloaded below or call the office to refer yourself or a patient in person.<\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e091f8c elementor-align-center elementor-widget elementor-widget-button\" data-id=\"e091f8c\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-xl\" href=\"\/wp-content\/uploads\/2022\/12\/Referral-Form-w-LS.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Referral Form PDF<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cbfc58c uael-gf-ajax-true uael-gf-style-box uael-gf-input-size-sm uael-gf-enable-classes-no uael-gf-button-left uael-gf-btn-size-sm elementor-widget elementor-widget-uael-gf-styler\" data-id=\"cbfc58c\" data-element_type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t\t<h3 class=\"uael-gf-form-title\">Referral Form<\/h3>\n\t\t<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_safari gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_2' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/wp-json\/wp\/v2\/pages\/4133' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_2_1\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_1\" ><label class='gfield_label gform-field-label' for='input_2_1'>Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='medium' maxlength='200'  tabindex='1'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_2\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_2\" ><label class='gfield_label gform-field-label' for='input_2_2'>Patient Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_2_2' type='text' value='' class='medium' maxlength='200'  tabindex='2'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_3\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_3\" ><label class='gfield_label gform-field-label' for='input_2_3'>Patient Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='medium' maxlength='20'  tabindex='3'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_10\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_10\" ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_2_12\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_12\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Preferred Periodontist:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_12'><li class='gchoice gchoice_2_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Dr. Peter Fritz'  id='choice_2_12_1' tabindex='4'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_1' id='label_2_12_1' class='gform-field-label gform-field-label--type-inline'>Dr. Peter Fritz<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Dr. Luisa Schuldt'  id='choice_2_12_2' tabindex='5'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_2' id='label_2_12_2' class='gform-field-label gform-field-label--type-inline'>Dr. Luisa Schuldt<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Earliest Available'  id='choice_2_12_3' tabindex='6'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_12_3' id='label_2_12_3' class='gform-field-label gform-field-label--type-inline'>Earliest Available<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_13\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_13\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Area of Treatment (pick one):<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_13'><li class='gchoice gchoice_2_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Generalized'  id='choice_2_13_1' tabindex='7'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>Generalized<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Specific Area\/Tooth'  id='choice_2_13_2' tabindex='8'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_13_2' id='label_2_13_2' class='gform-field-label gform-field-label--type-inline'>Specific Area\/Tooth<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_16\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_16\" ><label class='gfield_label gform-field-label' for='input_2_16'>Specific Tooth\/Area (if known):<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_2_16' type='text' value='' class='medium'   tabindex='9'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_2_5\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_5\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Service Required (pick one):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_5'><li class='gchoice gchoice_2_5_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.1' type='checkbox'  value='Implant Consultation'  id='choice_2_5_1' tabindex='10'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_1' id='label_2_5_1' class='gform-field-label gform-field-label--type-inline'>Implant Consultation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.2' type='checkbox'  value='Implant Maintenance'  id='choice_2_5_2' tabindex='11'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_2' id='label_2_5_2' class='gform-field-label gform-field-label--type-inline'>Implant Maintenance<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.3' type='checkbox'  value='Comprehensive Periodontal Examination (for Periodontal Disease)'  id='choice_2_5_3' tabindex='12'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_3' id='label_2_5_3' class='gform-field-label gform-field-label--type-inline'>Comprehensive Periodontal Examination (for Periodontal Disease)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.4' type='checkbox'  value='CBCT Imaging'  id='choice_2_5_4' tabindex='13'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_4' id='label_2_5_4' class='gform-field-label gform-field-label--type-inline'>CBCT Imaging<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.5' type='checkbox'  value='Evaluation of Recession\/Gum Grafting'  id='choice_2_5_5' tabindex='14'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_5' id='label_2_5_5' class='gform-field-label gform-field-label--type-inline'>Evaluation of Recession\/Gum Grafting<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.6' type='checkbox'  value='Biopsy\/Pathology'  id='choice_2_5_6' tabindex='15'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_6' id='label_2_5_6' class='gform-field-label gform-field-label--type-inline'>Biopsy\/Pathology<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.7' type='checkbox'  value='Atraumatic Extraction\/Socket Preservation'  id='choice_2_5_7' tabindex='16'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_7' id='label_2_5_7' class='gform-field-label gform-field-label--type-inline'>Atraumatic Extraction\/Socket Preservation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.8' type='checkbox'  value='Crown Lengthening'  id='choice_2_5_8' tabindex='17'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_8' id='label_2_5_8' class='gform-field-label gform-field-label--type-inline'>Crown Lengthening<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.9' type='checkbox'  value='Tooth Exposure'  id='choice_2_5_9' tabindex='18'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_9' id='label_2_5_9' class='gform-field-label gform-field-label--type-inline'>Tooth Exposure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.11' type='checkbox'  value='Frenectomy'  id='choice_2_5_11' tabindex='19'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_11' id='label_2_5_11' class='gform-field-label gform-field-label--type-inline'>Frenectomy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_5_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_5.12' type='checkbox'  value='Additional supportive periodontal therapy'  id='choice_2_5_12' tabindex='20'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_5_12' id='label_2_5_12' class='gform-field-label gform-field-label--type-inline'>Additional supportive periodontal therapy<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_14\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_14\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Are you interested in Sedation Dentistry?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_14'><li class='gchoice gchoice_2_14_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.1' type='checkbox'  value='Yes'  id='choice_2_14_1' tabindex='21'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_1' id='label_2_14_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_14_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.2' type='checkbox'  value='No'  id='choice_2_14_2' tabindex='22'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_2' id='label_2_14_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_14_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_14.3' type='checkbox'  value='Maybe. Tell me more.'  id='choice_2_14_3' tabindex='23'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_14_3' id='label_2_14_3' class='gform-field-label gform-field-label--type-inline'>Maybe. Tell me more.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_15\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_15\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Available Imaging:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_2_15'><li class='gchoice gchoice_2_15_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.1' type='checkbox'  value='No current diagnostic radiographs available'  id='choice_2_15_1' tabindex='24'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>No current diagnostic radiographs available<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_15_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.2' type='checkbox'  value='Current radiographs being sent by CDA Secure Send (for dental offices only)'  id='choice_2_15_2' tabindex='25'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_15_2' id='label_2_15_2' class='gform-field-label gform-field-label--type-inline'>Current radiographs being sent by CDA Secure Send (for dental offices only)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_15_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.3' type='checkbox'  value='Current radiographs being sent with patient'  id='choice_2_15_3' tabindex='26'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_15_3' id='label_2_15_3' class='gform-field-label gform-field-label--type-inline'>Current radiographs being sent with patient<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_15_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.4' type='checkbox'  value='Current radiographs being sent by Canada Post'  id='choice_2_15_4' tabindex='27'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_15_4' id='label_2_15_4' class='gform-field-label gform-field-label--type-inline'>Current radiographs being sent by Canada Post<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_2_15_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_15.5' type='checkbox'  value='Current radiographs being sent by secure email to webteam@drpeterfritz.com'  id='choice_2_15_5' tabindex='28'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_15_5' id='label_2_15_5' class='gform-field-label gform-field-label--type-inline'>Current radiographs being sent by secure email to webteam@drpeterfritz.com<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_2_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_2_17\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Referred by:<\/label><div 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