{"id":16663,"date":"2026-03-24T09:05:35","date_gmt":"2026-03-24T16:05:35","guid":{"rendered":"https:\/\/farsiodentadev.wpengine.com\/huntington-beach-ca\/?page_id=16663"},"modified":"2026-04-03T13:45:19","modified_gmt":"2026-04-03T20:45:19","slug":"doctor-referral-form","status":"publish","type":"page","link":"https:\/\/www.ocspecialtyendo.com\/huntington-beach-ca\/doctor-referral-form\/","title":{"rendered":"Doctor Referral Form"},"content":{"rendered":"<h4>Doctor Referral Forms for Endodontics, Periodontics, or Orthodontics<\/h4>\n<p><i>For referring doctors\u2019 office use only.<\/i><\/p>\n<p>You may refer patients to our Huntington Beach office by completing the online form below, or by downloading and printing the appropriate referral form. After completing the printed form, please fax it to 714-375-2199.<\/p>\n<div class=\"intWrap\">\n<a class=\"btn btn-orange intBtn\" href=\"\/wp-content\/uploads\/sites\/2\/2026\/04\/Current-Color-Endo-Referral.pdf\" download>Endodontics Form<\/a><br \/>\n<a class=\"btn btn-orange intBtn\" href=\"\/wp-content\/uploads\/sites\/2\/2026\/04\/Perio-Color-Referral.pdf\" download>Periodontics Form<\/a><br \/>\n<a class=\"btn btn-orange intBtn\" href=\"\/wp-content\/uploads\/sites\/2\/2026\/04\/Ortho-ColorReferral.pdf\" download>Orthodontics Form<\/a>\n<\/div>\n<h4>Doctor Referral Form<\/h4>\n<p>At Farsio Dental Specialties Group, we value our relationships with referring dental practices and are proud to partner with you to provide excellent oral healthcare to our community.<\/p>\n<p>To optimize care for our shared patients, we:<\/p>\n<ul>\n<li>Review cases thoroughly in advance<\/li>\n<li>Refer back to your office for restorations<\/li>\n<li>Collaborate with you on treatment plans<\/li>\n<li>Are available in an advisory role if requested<\/li>\n<li>Offer accommodating scheduling<\/li>\n<li>Provide timely assessments and imaging<\/li>\n<\/ul>\n<p>If you have any questions about our practice, please feel free to contact us. Above all, we want to thank you for your referral to our office.<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f16662-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"16662\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/huntington-beach-ca\/wp-json\/wp\/v2\/pages\/16663#wpcf7-f16662-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"16662\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f16662-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:16662,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;orthodontics-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;specialty-referral&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Orthodontics&quot;}]},{&quot;then_field&quot;:&quot;periodontics-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;specialty-referral&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Periodontics&quot;}]},{&quot;then_field&quot;:&quot;endodontics-group&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;specialty-referral&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Endodontics&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<\/fieldset>\n<div class=\"referral-form\">\n\t<h3>Referral Information\n\t<\/h3>\n\t<div class=\"form-row\">\n\t\t<p><label>Referring Doctor Name<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referring-doctor-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"referring-doctor-name\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-row\">\n\t\t<p><label>Referring Doctor Email<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"referring-doctor-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"referring-doctor-email\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-row\">\n\t\t<p><label>Appointment Date (preferred)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-appointment-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"preferred-appointment-date\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-row\">\n\t\t<p><label>X-Rays Available<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"xrays-available\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"xrays-available\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"xrays-available\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-row\">\n\t\t<p><label>Type of X-Ray<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"xray-type\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"xray-type\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"form-row\">\n\t\t<p><label>Date of X-Ray<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"xray-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"xray-date\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<h3>Specialty Referral\n\t<\/h3>\n\t<div class=\"form-row\">\n\t\t<p><label>Select Specialty*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"specialty-referral\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"specialty-referral[]\" value=\"Orthodontics\" \/><span class=\"wpcf7-list-item-label\">Orthodontics<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"specialty-referral[]\" value=\"Periodontics\" \/><span class=\"wpcf7-list-item-label\">Periodontics<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"specialty-referral[]\" value=\"Endodontics\" \/><span class=\"wpcf7-list-item-label\">Endodontics<\/span><\/label><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"orthodontics-group\" data-orig_data_id=\"orthodontics-group\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"specialty-group orthodontics-group\">\n\t\t\t<h4>Orthodontics\n\t\t\t<\/h4>\n\t\t\t<p><label>Services Recommended<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"orthodontics-services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"orthodontics-services[]\" value=\"Phase One Early Treatment\" \/><span class=\"wpcf7-list-item-label\">Phase One Early Treatment<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"orthodontics-services[]\" value=\"General Orthodontic Evaluation\" \/><span class=\"wpcf7-list-item-label\">General Orthodontic Evaluation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"orthodontics-services[]\" value=\"TMD\/Functional Concern\" \/><span class=\"wpcf7-list-item-label\">TMD\/Functional Concern<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"orthodontics-services[]\" value=\"Pre-Restorative Orthodontics\" \/><span class=\"wpcf7-list-item-label\">Pre-Restorative Orthodontics<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"form-row\">\n\t\t\t\t<p><label>Other<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"orthodontics-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"orthodontics-other\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"periodontics-group\" data-orig_data_id=\"periodontics-group\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"specialty-group periodontics-group\">\n\t\t\t<h4>Periodontics\n\t\t\t<\/h4>\n\t\t\t<h3>Tooth Selection\n\t\t\t<\/h3>\n\t\t\t<p>*Please select each tooth below*\n\t\t\t<\/p>\n\t\t\t<div class=\"tooth-board\">\n\t\t\t\t<div class=\"tooth-col mol\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Molars\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_u_1\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_u_1[]\" value=\"1\" \/><span class=\"wpcf7-list-item-label\">1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_u_1[]\" value=\"2\" \/><span class=\"wpcf7-list-item-label\">2<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_u_1[]\" value=\"3\" \/><span class=\"wpcf7-list-item-label\">3<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_l_1\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_l_1[]\" value=\"32\" \/><span class=\"wpcf7-list-item-label\">32<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_l_1[]\" value=\"31\" \/><span class=\"wpcf7-list-item-label\">31<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_l_1[]\" value=\"30\" \/><span class=\"wpcf7-list-item-label\">30<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col bic\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Bicuspids\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_u_2\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_u_2[]\" value=\"4\" \/><span class=\"wpcf7-list-item-label\">4<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_u_2[]\" value=\"5\" \/><span class=\"wpcf7-list-item-label\">5<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_l_2\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_l_2[]\" value=\"29\" \/><span class=\"wpcf7-list-item-label\">29<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_l_2[]\" value=\"28\" \/><span class=\"wpcf7-list-item-label\">28<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col ant\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Anteriors\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_u_3\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_u_3[]\" value=\"6\" \/><span class=\"wpcf7-list-item-label\">6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_u_3[]\" value=\"7\" \/><span class=\"wpcf7-list-item-label\">7<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_u_3[]\" value=\"8\" \/><span class=\"wpcf7-list-item-label\">8<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_l_3\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_l_3[]\" value=\"27\" \/><span class=\"wpcf7-list-item-label\">27<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_l_3[]\" value=\"26\" \/><span class=\"wpcf7-list-item-label\">26<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_l_3[]\" value=\"25\" \/><span class=\"wpcf7-list-item-label\">25<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col ant\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Anteriors\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_u_4\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_u_4[]\" value=\"9\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_u_4[]\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_u_4[]\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_l_4\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_l_4[]\" value=\"24\" \/><span class=\"wpcf7-list-item-label\">24<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_l_4[]\" value=\"23\" \/><span class=\"wpcf7-list-item-label\">23<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_l_4[]\" value=\"22\" \/><span class=\"wpcf7-list-item-label\">22<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col bic\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Bicuspids\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_u_5\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_u_5[]\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_u_5[]\" value=\"13\" \/><span class=\"wpcf7-list-item-label\">13<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_l_5\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_l_5[]\" value=\"21\" \/><span class=\"wpcf7-list-item-label\">21<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_l_5[]\" value=\"20\" \/><span class=\"wpcf7-list-item-label\">20<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col mol\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Molars\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_u_6\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_u_6[]\" value=\"14\" \/><span class=\"wpcf7-list-item-label\">14<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_u_6[]\" value=\"15\" \/><span class=\"wpcf7-list-item-label\">15<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_u_6[]\" value=\"16\" \/><span class=\"wpcf7-list-item-label\">16<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"teeth_l_6\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"teeth_l_6[]\" value=\"19\" \/><span class=\"wpcf7-list-item-label\">19<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"teeth_l_6[]\" value=\"18\" \/><span class=\"wpcf7-list-item-label\">18<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"teeth_l_6[]\" value=\"17\" \/><span class=\"wpcf7-list-item-label\">17<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<p><label>Services Recommended (select all that apply)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"periodontics-services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Full-Mouth Periodontal Exam\" \/><span class=\"wpcf7-list-item-label\">Full-Mouth Periodontal Exam<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Limited Periodontal Exam\" \/><span class=\"wpcf7-list-item-label\">Limited Periodontal Exam<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Periodontal Pockets\" \/><span class=\"wpcf7-list-item-label\">Periodontal Pockets<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Dental Implants\" \/><span class=\"wpcf7-list-item-label\">Dental Implants<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Extraction\/Socket Preservation\" \/><span class=\"wpcf7-list-item-label\">Extraction\/Socket Preservation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Ridge Augmentation\" \/><span class=\"wpcf7-list-item-label\">Ridge Augmentation<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Soft Tissue Lift\" \/><span class=\"wpcf7-list-item-label\">Soft Tissue Lift<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Sinus Lift\" \/><span class=\"wpcf7-list-item-label\">Sinus Lift<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Osseous Surgery or Bone Graft\" \/><span class=\"wpcf7-list-item-label\">Osseous Surgery or Bone Graft<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Crown Lengthening\" \/><span class=\"wpcf7-list-item-label\">Crown Lengthening<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"All-on-4 or All-on-6\" \/><span class=\"wpcf7-list-item-label\">All-on-4 or All-on-6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Failing Implant Rescue\" \/><span class=\"wpcf7-list-item-label\">Failing Implant Rescue<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"periodontics-services[]\" value=\"Biopsy (Hard\/Soft Tissue)\" \/><span class=\"wpcf7-list-item-label\">Biopsy (Hard\/Soft Tissue)<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"form-row\">\n\t\t\t\t<p><label>Other<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"periodontics-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"periodontics-other\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"form-row\">\n\t\t\t\t<p><label>Analgesic\/Antibiotic Prescribed<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"periodontics-medication\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"periodontics-medication\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div data-id=\"endodontics-group\" data-orig_data_id=\"endodontics-group\" data-clear_on_hide class=\"\" data-class=\"wpcf7cf_group\">\n\t\t<div class=\"specialty-group endodontics-group\">\n\t\t\t<h4>Endodontics\n\t\t\t<\/h4>\n\t\t\t<h3>Tooth Selection\n\t\t\t<\/h3>\n\t\t\t<p>*Please select each tooth below*\n\t\t\t<\/p>\n\t\t\t<div class=\"tooth-board\">\n\t\t\t\t<div class=\"tooth-col mol\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Molars\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_u_1\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_u_1[]\" value=\"1\" \/><span class=\"wpcf7-list-item-label\">1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_u_1[]\" value=\"2\" \/><span class=\"wpcf7-list-item-label\">2<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_u_1[]\" value=\"3\" \/><span class=\"wpcf7-list-item-label\">3<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_l_1\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_l_1[]\" value=\"32\" \/><span class=\"wpcf7-list-item-label\">32<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_l_1[]\" value=\"31\" \/><span class=\"wpcf7-list-item-label\">31<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_l_1[]\" value=\"30\" \/><span class=\"wpcf7-list-item-label\">30<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col bic\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Bicuspids\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_u_2\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_u_2[]\" value=\"4\" \/><span class=\"wpcf7-list-item-label\">4<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_u_2[]\" value=\"5\" \/><span class=\"wpcf7-list-item-label\">5<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_l_2\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_l_2[]\" value=\"29\" \/><span class=\"wpcf7-list-item-label\">29<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_l_2[]\" value=\"28\" \/><span class=\"wpcf7-list-item-label\">28<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col ant\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Anteriors\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_u_3\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_u_3[]\" value=\"6\" \/><span class=\"wpcf7-list-item-label\">6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_u_3[]\" value=\"7\" \/><span class=\"wpcf7-list-item-label\">7<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_u_3[]\" value=\"8\" \/><span class=\"wpcf7-list-item-label\">8<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_l_3\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_l_3[]\" value=\"27\" \/><span class=\"wpcf7-list-item-label\">27<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_l_3[]\" value=\"26\" \/><span class=\"wpcf7-list-item-label\">26<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_l_3[]\" value=\"25\" \/><span class=\"wpcf7-list-item-label\">25<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col ant\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Anteriors\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_u_4\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_u_4[]\" value=\"9\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_u_4[]\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_u_4[]\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_l_4\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_l_4[]\" value=\"24\" \/><span class=\"wpcf7-list-item-label\">24<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_l_4[]\" value=\"23\" \/><span class=\"wpcf7-list-item-label\">23<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_l_4[]\" value=\"22\" \/><span class=\"wpcf7-list-item-label\">22<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col bic\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Bicuspids\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_u_5\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_u_5[]\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_u_5[]\" value=\"13\" \/><span class=\"wpcf7-list-item-label\">13<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_l_5\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_l_5[]\" value=\"21\" \/><span class=\"wpcf7-list-item-label\">21<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_l_5[]\" value=\"20\" \/><span class=\"wpcf7-list-item-label\">20<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"tooth-col mol\">\n\t\t\t\t\t<div class=\"tooth-col__head\">\n\t\t\t\t\t\t<p>Molars\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row upper\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_u_6\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_u_6[]\" value=\"14\" \/><span class=\"wpcf7-list-item-label\">14<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_u_6[]\" value=\"15\" \/><span class=\"wpcf7-list-item-label\">15<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_u_6[]\" value=\"16\" \/><span class=\"wpcf7-list-item-label\">16<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"tooth-row lower\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"endo_teeth_l_6\"><span class=\"wpcf7-form-control wpcf7-checkbox tooth\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endo_teeth_l_6[]\" value=\"19\" \/><span class=\"wpcf7-list-item-label\">19<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endo_teeth_l_6[]\" value=\"18\" \/><span class=\"wpcf7-list-item-label\">18<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endo_teeth_l_6[]\" value=\"17\" \/><span class=\"wpcf7-list-item-label\">17<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<p><label>Services Recommended (select all that apply)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"endodontics-services\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Consultations and Diagnosis\" \/><span class=\"wpcf7-list-item-label\">Consultations and Diagnosis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Pulp Exposed (Vital\/Nonvital)\" \/><span class=\"wpcf7-list-item-label\">Pulp Exposed (Vital\/Nonvital)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Radiolucency and Pulpal Involvement Noted\" \/><span class=\"wpcf7-list-item-label\">Radiolucency and Pulpal Involvement Noted<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Pain\/Swelling or Sensitivity\" \/><span class=\"wpcf7-list-item-label\">Pain\/Swelling or Sensitivity<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Endodontics Necessary for Proper Restoration\" \/><span class=\"wpcf7-list-item-label\">Endodontics Necessary for Proper Restoration<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Final Restoration\" \/><span class=\"wpcf7-list-item-label\">Final Restoration<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Prepare Post Space\" \/><span class=\"wpcf7-list-item-label\">Prepare Post Space<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Place Post and Buildup\" \/><span class=\"wpcf7-list-item-label\">Place Post and Buildup<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"endodontics-services[]\" value=\"Please Evaluate and Treat as Necessary\" \/><span class=\"wpcf7-list-item-label\">Please Evaluate and Treat as Necessary<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"form-row\">\n\t\t\t\t<p><label>Other findings or notes<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"endodontics-notes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"endodontics-notes\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"form-row\">\n\t\t\t\t<p><label>Analgesic prescribed<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"endodontics-analgesic\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"endodontics-analgesic\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t\t<div class=\"form-row\">\n\t\t\t\t<p><label>Antibiotics prescribed<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"endodontics-antibiotics\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"endodontics-antibiotics\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"form-row submit-row\">\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Referral\" \/>\n\t\t<\/p>\n\t<\/div>\n<\/div><input type=\"hidden\" id=\"ct_checkjs_cf7_298f95e1bf9136124592c8d4825a06fc\" name=\"ct_checkjs_cf7\" value=\"0\" \/><script >setTimeout(function(){var ct_input_name = \"ct_checkjs_cf7_298f95e1bf9136124592c8d4825a06fc\";if (document.getElementById(ct_input_name) !== null) {var ct_input_value = document.getElementById(ct_input_name).value;document.getElementById(ct_input_name).value = document.getElementById(ct_input_name).value.replace(ct_input_value, '205c056011034f09de33fa4fffb542f2f80b7bb41c8273d78e9efda298aa3a30');}}, 1000);<\/script><input\n                    class=\"apbct_special_field apbct_email_id__wp_contact_form_7\"\n                    name=\"apbct__email_id__wp_contact_form_7\"\n                    aria-label=\"apbct__label_id__wp_contact_form_7\"\n                    type=\"text\" size=\"30\" maxlength=\"200\" autocomplete=\"off\"\n                    value=\"\"\n                \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<p>If you have any questions, please call our office.<\/p>\n<h4>Office Hours<\/h4>\n<p>Monday through Friday: 9:00 AM - 6:00 PM<br \/>\nSaturday: 7:00 AM - 3:00 PM<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Doctor Referral Forms for Endodontics, Periodontics, or Orthodontics For referring doctors\u2019 office use only. You may refer patients to our Huntington Beach office by completing the online form below, or by downloading and printing the appropriate referral form. After completing the printed form, please fax it to 714-375-2199. 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