{"id":148,"date":"2026-02-23T13:51:17","date_gmt":"2026-02-23T13:51:17","guid":{"rendered":"https:\/\/www.smiletown.ca\/blog\/?page_id=148"},"modified":"2026-02-23T13:51:17","modified_gmt":"2026-02-23T13:51:17","slug":"refer-a-patient-1","status":"publish","type":"page","link":"https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/","title":{"rendered":"Refer a Patient"},"content":{"rendered":"\n<div style=\"height:50px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\">We\u2019re Here to Provide Child-Friendly Dental Care<\/h2>\n\n\n\n<p>Are you interested in referring a young patient to our office for oral healthcare? If so, we invite you to fill out the following form. By providing us with the essential information and reason for the referral, we can be sure to administer appropriate care from beginning to end. We\u2019ll also remain in contact with you should you require updates.<\/p>\n\n\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital contained-form_wrapper' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_4' ><style>#gform_wrapper_4[data-form-index=\"0\"].gform-theme,[data-parent-form=\"4_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg width='640' height='640' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><form method='post' enctype='multipart\/form-data'  id='gform_4' class='contained-form' action='\/blog\/wp-json\/wp\/v2\/pages\/148' data-formid='4' novalidate>\t\t\t\t\t<div style=\"display: none !important;\" class=\"akismet-fields-container gf_invisible\" data-prefix=\"ak_\">\n\t\t\t\t\t\t<label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label>\n\t\t\t\t\t\t<input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"180\" \/>\n\t\t\t\t\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n\n\t\t\t\t\t<\/div><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeIJcUrAAAAAITC6XOvByPdoDJ7BDRARi32PkFZ' data-tabindex='0'><input id=\"input_35be03f21148cf7daf00d9edcddf7231\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_35be03f21148cf7daf00d9edcddf7231\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Dentist Information<\/h3><\/div><div id=\"field_4_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_28'>Dentist Office Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_4_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_2'>Dentist Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_4_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_3'>Dentist Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_3' id='input_4_3' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_4'>Dentist Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_4_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Insurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_5'>\n\t\t\t<div class='gchoice gchoice_4_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Yes'  id='choice_4_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_5_0' id='label_4_5_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='No'  id='choice_4_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_5_1' id='label_4_5_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Healthy Smiles Ontario'  id='choice_4_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_5_2' id='label_4_5_2' class='gform-field-label gform-field-label--type-inline'>Healthy Smiles Ontario<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_5_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Canadian Dental Care Program'  id='choice_4_5_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_5_3' id='label_4_5_3' class='gform-field-label gform-field-label--type-inline'>Canadian Dental Care Program<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_6'>Insurance Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_4_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient Information<\/h3><\/div><div id=\"field_4_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_8'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_4_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_9'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_4_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Reason for Referral<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_10'>\n\t\t\t<div class='gchoice gchoice_4_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Conscious Sedation'  id='choice_4_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_10_0' id='label_4_10_0' class='gform-field-label gform-field-label--type-inline'>Conscious Sedation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Deep\/IV Sedation'  id='choice_4_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_10_1' id='label_4_10_1' class='gform-field-label gform-field-label--type-inline'>Deep\/IV Sedation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Age\/Behavioural'  id='choice_4_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_10_2' id='label_4_10_2' class='gform-field-label gform-field-label--type-inline'>Age\/Behavioural<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_11'>Home Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_11' id='input_4_11' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_12\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_12'>Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_4_12' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Main Contact Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_13'>\n\t\t\t<div class='gchoice gchoice_4_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Home'  id='choice_4_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_13_0' id='label_4_13_0' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Work'  id='choice_4_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_13_1' id='label_4_13_1' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Cell'  id='choice_4_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_13_2' id='label_4_13_2' class='gform-field-label gform-field-label--type-inline'>Cell<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_14\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_4_14' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_15'>Contact Person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_4_15' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Patient Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_16'>\n\t\t\t<div class='gchoice gchoice_4_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Male'  id='choice_4_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_16_0' id='label_4_16_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Female'  id='choice_4_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_16_1' id='label_4_16_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Prefer not to say'  id='choice_4_16_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_16_2' id='label_4_16_2' class='gform-field-label gform-field-label--type-inline'>Prefer not to say<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>Patient Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_4_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_17' class='gform_hidden' value='https:\/\/www.smiletown.ca\/blog\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_18\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_18'>Treatment Required<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_4_18' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_19\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">X-Ray Information<\/h3><\/div><fieldset id=\"field_4_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >X-Rays Available?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_20'>\n\t\t\t<div class='gchoice gchoice_4_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Yes'  id='choice_4_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_20_0' id='label_4_20_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='No'  id='choice_4_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_20_1' id='label_4_20_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_21\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_4_21'>Attach X-Ray(s)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_4_21' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_4_21&quot;,&quot;container&quot;:&quot;gform_multifile_upload_4_21&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_4_21&quot;,&quot;filelist&quot;:&quot;gform_preview_4_21&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.smiletown.ca\\\/blog\\\/?gf_page=4607bb845115df5&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.smiletown.ca\\\/blog\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.smiletown.ca\\\/blog\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;268435456b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:4,&quot;field_id&quot;:21,&quot;_gform_file_upload_nonce_4_21&quot;:&quot;04c3dd1d4f&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;10&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_4_21&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_4_21' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_4_21' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_4_21 gfield_description_4_21\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_21'>Max. file size: 256 MB, Max. files: 10.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_4_21'><\/ul> <div id='gform_preview_4_21' class='ginput_preview_list'><\/div><\/div><div class='gfield_description' id='gfield_description_4_21'>Max. file size: 50 MB.<\/div><\/div><div id=\"field_4_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_22'>Date(s) of Attached X-Ray(s)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_4_22' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_23\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Additional Information<\/h3><\/div><div id=\"field_4_24\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_24'>Does Your Patient Have Any Significant Medical History That We Should Know Of?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_24' id='input_4_24' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_4_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Is Your Patient Travelling More Than 25km To Our Office?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_25'>\n\t\t\t<div class='gchoice gchoice_4_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_4_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_25_0' id='label_4_25_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_4_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_25_1' id='label_4_25_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Does Your Patient Require a Translator?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_26'>\n\t\t\t<div class='gchoice gchoice_4_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_4_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_26_0' id='label_4_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_4_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_26_1' id='label_4_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Send to Office Location:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_27'>\n\t\t\t<div class='gchoice gchoice_4_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Cambridge'  id='choice_4_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_0' id='label_4_27_0' class='gform-field-label gform-field-label--type-inline'>Cambridge<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Waterloo'  id='choice_4_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_1' id='label_4_27_1' class='gform-field-label gform-field-label--type-inline'>Waterloo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Guelph'  id='choice_4_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_27_2' id='label_4_27_2' class='gform-field-label gform-field-label--type-inline'>Guelph<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit Referral'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='{&quot;theme&quot;:&quot;orbital&quot;,&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='lDTQWjpzinokvCEkKxy+PpMfGgD8PdqggdEBZTb2QudXpqIkyDdsfNeHTq\/7BlbPs\/P7\/U3u0aTSlTvuA4\/dn5heqX+uOm8Ql+vy3rAI5lv4aIc=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' value='WyJbXSIsImU5M2I2ZTVkOWNhMWQyNjQwMDhjYzY4NDYyNGQyOGZlIl0=' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_4' id='gform_target_page_number_4' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_4' id='gform_source_page_number_4' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_4' value='' \/>\n        <\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 4, 'https:\/\/www.smiletown.ca\/blog\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_4').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_4');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_4').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_4').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_4').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_4').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_4').val();gformInitSpinner( 4, 'https:\/\/www.smiletown.ca\/blog\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [4, current_page]);window['gf_submitting_4'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_4').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [4]);window['gf_submitting_4'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_4').text());}else{jQuery('#gform_4').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"4\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_4\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_4\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_4\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 4, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n","protected":false},"excerpt":{"rendered":"<p>We\u2019re Here to Provide Child-Friendly Dental Care Are you interested in referring a young patient to our office for oral healthcare? If so, we invite you to fill out the following form. By providing us with the essential information and reason for the referral, we can be sure to administer appropriate care from beginning to [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-148","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Refer a Patient - Smile Town Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:title\" content=\"Refer a Patient - Smile Town Blog\" \/>\n<meta name=\"twitter:description\" content=\"We\u2019re Here to Provide Child-Friendly Dental Care Are you interested in referring a young patient to our office for oral healthcare? If so, we invite you to fill out the following form. By providing us with the essential information and reason for the referral, we can be sure to administer appropriate care from beginning to [&hellip;]\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/refer-a-patient-1\\\/\",\"url\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/refer-a-patient-1\\\/\",\"name\":\"Refer a Patient - Smile Town Blog\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/#website\"},\"datePublished\":\"2026-02-23T13:51:17+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/refer-a-patient-1\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/refer-a-patient-1\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/refer-a-patient-1\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Refer a Patient\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/#website\",\"url\":\"https:\\\/\\\/www.smiletown.ca\\\/blog\\\/\",\"name\":\"Smile Town Blog\",\"description\":\"\",\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Refer a Patient - Smile Town Blog","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/","twitter_card":"summary_large_image","twitter_title":"Refer a Patient - Smile Town Blog","twitter_description":"We\u2019re Here to Provide Child-Friendly Dental Care Are you interested in referring a young patient to our office for oral healthcare? If so, we invite you to fill out the following form. By providing us with the essential information and reason for the referral, we can be sure to administer appropriate care from beginning to [&hellip;]","schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/","url":"https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/","name":"Refer a Patient - Smile Town Blog","isPartOf":{"@id":"https:\/\/www.smiletown.ca\/blog\/#website"},"datePublished":"2026-02-23T13:51:17+00:00","breadcrumb":{"@id":"https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/www.smiletown.ca\/blog\/refer-a-patient-1\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/www.smiletown.ca\/blog\/"},{"@type":"ListItem","position":2,"name":"Refer a Patient"}]},{"@type":"WebSite","@id":"https:\/\/www.smiletown.ca\/blog\/#website","url":"https:\/\/www.smiletown.ca\/blog\/","name":"Smile Town Blog","description":"","inLanguage":"en-US"}]}},"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/pages\/148","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/comments?post=148"}],"version-history":[{"count":1,"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/pages\/148\/revisions"}],"predecessor-version":[{"id":149,"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/pages\/148\/revisions\/149"}],"wp:attachment":[{"href":"https:\/\/www.smiletown.ca\/blog\/wp-json\/wp\/v2\/media?parent=148"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}