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		<title>Referral Page | Niagara Dental Implant & Oral Surgery</title>
		<meta name="description" content="Niagara Dental Implant & Oral Surgery 6490 Main Street, Suite 5, Williamsville, NY 14221, offers a full survey form to understand your needs. Don’t dismiss it to enjoy quality services in a few clicks!" />
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		<header class="lp_header">
			<div class="container">
				<div class="row align-items-center">
					<div class="col-md-6 col-sm-6 col-7 default-padding">
						<div class="header_logo">
							<img src="lp-asset/lp-images/logo-new.svg" alt="">
						</div>
					</div>
				</div>
			</div>
		</header>
		<section class="refferral-form-section">
			<div class="container">
				<div class="row">
					<div class="col-12">
						<form id="refferal_form">
							<div class="referral-form-main">
								<div class="referral-form-inner" id="referral01">
									<div class="form-title-main">
										<h2>Demographic Information</h2>
									</div>
									<div class="form-content-wrap">
										<div class="form-content-title">
											<h3>Patient Information</h3>
										</div>
										<div class="form-content-wrapper">
											<div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-md-3">
														<div class="form-row-label">
															<label for="" class="row-label">Patient Name:</label>
														</div>
													</div>
													<div class="col-md-4 col-sm-6">
														<div class="form-row-input">
															<input type="text" id="first_name" name="first_name" placeholder="First Name">
														</div>
													</div>
													<div class="col-md-5 col-sm-6">
														<div class="form-row-input">
															<input type="text" id="last_name" name="last_name" placeholder="Last Name">
														</div>
													</div>
												</div>
											</div>
											<div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-md-3">
														<div class="form-row-label">
															<label for="" class="row-label">Cell Phone Number:</label>
														</div>
													</div>
													<div class="col-md-9">
														<div class="form-row-input">
															<input type="text" id="patient_phone_number" name="patient_phone_number" placeholder="Cell Phone Number">
														</div>
														<div class="form-row-label">
															<label for="" class="row-label">Please provide your patient’s cell phone number so we can initiate the concierge process.</label>
														</div>
													</div>
												</div>
											</div>
											<div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-md-3">
														<div class="form-row-label">
															<label for="" class="row-label">Date of Birth:</label>
														</div>
													</div>
													<div class="col-md-9">
														<div class="form-row-input">
															<input type="text" id="date_of_birth" name="date_of_birth" placeholder="Date of Birth">
														</div>
													</div>
												</div>
											</div>
											<div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-md-3">
														<div class="form-row-label">
															<label for="" class="row-label">Date of X-Ray:</label>
														</div>
													</div>
													<div class="col-md-9">
														<div class="form-row-input">
															<input type="text" id="date_of_xray" name="date_of_xray" placeholder="Date of X-Ray">
														</div>
														<div class="form-row-label">
															<label for="" class="row-label">Upload x-rays, imaging, or other documentation on the next page.</label>
														</div>
													</div>
												</div>
											</div>
											<!-- <div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-12">
														<div class="form-row-label">
															<label for="" class="row-label">Please Provide Patient Phone Number So That We May Begin The Concierge Process</label>
														</div>
													</div>
												</div>
											</div> -->
										</div>
									</div>
								</div>
								<div class="referral-form-inner" id="referral02">
									<div class="form-title-main">
										<h2>Referring Information</h2>
									</div>
									<div class="form-content-wrap">
										<div class="form-content-title">
											<h3>Referring Doctor Information</h3>
										</div>
										<div class="form-content-wrapper">
											<div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-md-3">
														<div class="form-row-label">
															<label for="" class="row-label">Referring Doctor:</label>
														</div>
													</div>
													<div class="col-md-4 col-sm-6">
														<div class="form-row-input">
															<input type="text" id="referring_doctor_first_name" name="referring_doctor_first_name" placeholder="First Name">
														</div>
													</div>
													<div class="col-md-5 col-sm-6">
														<div class="form-row-input">
															<input type="text" id="referring_doctor_last_name" name="referring_doctor_last_name" placeholder="Last Name">
														</div>
													</div>
												</div>
											</div>
											<div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-md-3">
														<div class="form-row-label">
															<label for="" class="row-label">Referring Doctor Phone Number:</label>
														</div>
													</div>
													<div class="col-md-9">
														<div class="form-row-input">
															<input type="text" id="referring_doctor_phone_number" name="referring_doctor_phone_number" placeholder="Phone Number">
														</div>
													</div>
												</div>
											</div>
										</div>
									</div>
								</div>
								<div class="referral-form-inner" id="referral03">
									<div class="form-title-main">
										<h2>Treatment Information</h2>
									</div>
									<div class="form-content-wrap">
										<div class="form-content-title">
											<h3>Diagnosis:</h3>
										</div>
										<div class="form-content-wrapper">
											<div class="form-content-row">
												<div class="row align-items-center">
													<div class="col-lg-3 col-sm-4">
														<div class="form-row-label">
															<label for="diagnosis" class="row-label">Diagnosis:</label>
														</div>
													</div>
													<div class="col-lg-9 col-sm-8">
														<div class="form-row-input">
															<select name="diagnosis" id="diagnosis">
																<option value="">Please Choose</option>
																<option value="Caries">Caries</option>
																<option value="Impaction">Impaction</option>
																<option value="Cracked tooth">Cracked tooth</option>
																<option value="Failed Endodontic Tx">Failed Endodontic Tx</option>
																<option value="Periodontitis">Periodontitis</option>
																<option value="Alveolar atrophy">Alveolar atrophy</option>
																<option value="Other">Other</option>
															</select>
														</div>
													</div>
												</div>
											</div>
											<div class="form-content-row diagnosis_div" style="display: none;">
												<div class="row align-items-center">
													<div class="col-12">
														<div class="form-row-input">
															<textarea type="text" id="diagnosis_other" name="diagnosis_other" placeholder="Other Diagnosis Specification" rows="3"></textarea>
														</div>
													</div>
												</div>
											</div>
										</div>
									</div>
									<div class="form-content-wrap">
										<div class="form-content-title">
											<h3>Permanent:</h3>
										</div>
										<div class="form-content-wrapper">
											<div class="form-content-row">
												<div class="teeth_number_main">
													<div class="teeth_number_right teeth_number_rf">right</div>
													<table align="center" class="teeth_number">
														<tr class="teeth-top">
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="1" value="1">
																<img src="/lp-asset/lp-images/referral-page-image/d1.png" alt="d1">
																<span></span>
																<div class="teeth-number">1</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="2" value="2">
																<img src="/lp-asset/lp-images/referral-page-image/d2.png" alt="d2">
																<span></span>
																<div class="teeth-number">2</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="3" value="3">
																<img src="/lp-asset/lp-images/referral-page-image/d3.png" alt="d3">
																<span></span>
																<div class="teeth-number">3</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="4" value="4">
																<img src="/lp-asset/lp-images/referral-page-image/d4.png" alt="d4">
																<span></span>
																<div class="teeth-number">4</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="5" value="5">
																<img src="/lp-asset/lp-images/referral-page-image/d5.png" alt="d5">
																<span></span>
																<div class="teeth-number">5</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="6" value="6">
																<img src="/lp-asset/lp-images/referral-page-image/d6.png" alt="d6">
																<span></span>
																<div class="teeth-number">6</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="7" value="7">
																<img src="/lp-asset/lp-images/referral-page-image/d7.png" alt="d7">
																<span></span>
																<div class="teeth-number">7</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="8" value="8">
																<img src="/lp-asset/lp-images/referral-page-image/d8.png" alt="d8">
																<span></span>
																<div class="teeth-number">8</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="9" value="9">
																<img src="/lp-asset/lp-images/referral-page-image/d9.png" alt="d9">
																<span></span>
																<div class="teeth-number">9</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="10" value="10">
																<img src="/lp-asset/lp-images/referral-page-image/d10.png" alt="d10">
																<span></span>
																<div class="teeth-number">10</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="11" value="11">
																<img src="/lp-asset/lp-images/referral-page-image/d11.png" alt="d11">
																<span></span>
																<div class="teeth-number">11</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="12" value="12">
																<img src="/lp-asset/lp-images/referral-page-image/d12.png" alt="d12">
																<span></span>
																<div class="teeth-number">12</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="13" value="13">
																<img src="/lp-asset/lp-images/referral-page-image/d13.png" alt="d13">
																<span></span>
																<div class="teeth-number">13</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="14" value="14">
																<img src="/lp-asset/lp-images/referral-page-image/d14.png" alt="d14">
																<span></span>
																<div class="teeth-number">14</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="15" value="15">
																<img src="/lp-asset/lp-images/referral-page-image/d15.png" alt="d15">
																<span></span>
																<div class="teeth-number">15</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="permanent_teeth[]" id="16" value="16">
																<img src="/lp-asset/lp-images/referral-page-image/d16.png" alt="d16">
																<span></span>
																<div class="teeth-number">16</div>
															</td>
														</tr>
														<tr class="teeth-bottom">
															<td valign="top">
																<div class="teeth-number">32</div>
																<input type="checkbox" name="permanent_teeth[]" id="32" value="32">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d32.png" alt="d32">
															</td>
															<td valign="top">
																<div class="teeth-number">31</div>
																<input type="checkbox" name="permanent_teeth[]" id="31" value="31">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d31.png" alt="d31">
															</td>
															<td valign="top">
																<div class="teeth-number">30</div>
																<input type="checkbox" name="permanent_teeth[]" id="30" value="30">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d30.png" alt="d30">
															</td>
															<td valign="top">
																<div class="teeth-number">29</div>
																<input type="checkbox" name="permanent_teeth[]" id="29" value="29">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d29.png" alt="d29">
															</td>
															<td valign="top">
																<div class="teeth-number">28</div>
																<input type="checkbox" name="permanent_teeth[]" id="28" value="28">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d28.png" alt="d28">
															</td>
															<td valign="top">
																<div class="teeth-number">27</div>
																<input type="checkbox" name="permanent_teeth[]" id="27" value="27">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d27.png" alt="d27">
															</td>
															<td valign="top">
																<div class="teeth-number">26</div>
																<input type="checkbox" name="permanent_teeth[]" id="26" value="26">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d26.png" alt="d26">
															</td>
															<td valign="top">
																<div class="teeth-number">25</div>
																<input type="checkbox" name="permanent_teeth[]" id="25" value="25">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d25.png" alt="d25">
															</td>
															<td valign="top">
																<div class="teeth-number">24</div>
																<input type="checkbox" name="permanent_teeth[]" id="24" value="24">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d24.png" alt="d24">
															</td>
															<td valign="top">
																<div class="teeth-number">23</div>
																<input type="checkbox" name="permanent_teeth[]" id="23" value="23">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d23.png" alt="d23">
															</td>
															<td valign="top">
																<div class="teeth-number">22</div>
																<input type="checkbox" name="permanent_teeth[]" id="22" value="22">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d22.png" alt="d22">
															</td>
															<td valign="top">
																<div class="teeth-number">21</div>
																<input type="checkbox" name="permanent_teeth[]" id="21" value="21">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d21.png" alt="d21">
															</td>
															<td valign="top">
																<div class="teeth-number">20</div>
																<input type="checkbox" name="permanent_teeth[]" id="20" value="20">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d20.png" alt="d20">
															</td>
															<td valign="top">
																<div class="teeth-number">19</div>
																<input type="checkbox" name="permanent_teeth[]" id="19" value="19">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d19.png" alt="d19">
															</td>
															<td valign="top">
																<div class="teeth-number">18</div>
																<input type="checkbox" name="permanent_teeth[]" id="18" value="18">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d18.png" alt="d18">
															</td>
															<td valign="top">
																<div class="teeth-number">17</div>
																<input type="checkbox" name="permanent_teeth[]" id="17" value="17">
																<span></span>
																<img src="/lp-asset/lp-images/referral-page-image/d17.png" alt="d17">
															</td>
														</tr>
													</table>
													<div class="teeth_number_right teeth_number_rf">left</div>
												</div>
											</div>
										</div>
									</div>
									<div class="form-content-wrap">
										<div class="form-content-title">
											<h3>Deciduous:</h3>
										</div>
										<div class="form-content-wrapper">
											<div class="form-content-row">
												<div class="teeth_number_main">
													<div class="teeth_number_right teeth_number_rf">right</div>
													<table align="center" class="teeth_number">
														<tr class="teeth-top">
															<td valign="bottom">
																<input type="checkbox" name="primary_teeth[]" id="a" value="a">
																<img src="/lp-asset/lp-images/referral-page-image/da.png" alt="da">
																<span></span>
																<div class="teeth-number">a</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="primary_teeth[]" id="b" value="b">
																<img src="/lp-asset/lp-images/referral-page-image/db.png" alt="db">
																<span></span>
																<div class="teeth-number">b</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="primary_teeth[]" id="c" value="c">
																<img src="/lp-asset/lp-images/referral-page-image/dc.png" alt="dc">
																<span></span>
																<div class="teeth-number">c</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="primary_teeth[]" id="d" value="d">
																<img src="/lp-asset/lp-images/referral-page-image/dd.png" alt="dd">
																<span></span>
																<div class="teeth-number">d</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="primary_teeth[]" id="e" value="e">
																<img src="/lp-asset/lp-images/referral-page-image/de.png" alt="de">
																<span></span>
																<div class="teeth-number">e</div>
															</td>
															<td valign="bottom">
																<input type="checkbox" name="primary_teeth[]" id="f" value="f">
																<img src="/lp-asset/lp-images/referral-page-image/df.png" alt="df">
																<span></span>
																<div class="teeth-number">f</div>
															</td>
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																		<label for="" class="row-label">• Please note restoration shade in your records for future Rx</label><br>
																		<label for="" class="row-label">• Lab will be instructed to await Rx from restorative doctor</label><br>
																		<label for="" class="row-label">• We will send implant correspondence when implant is ready to be restored.</label>
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														<p class="mb-2"><b>All patients must have a pre-surgical consultation with Dr. Nigalye before scheduling surgery.</b></p>
														<p class="mb-2">Please notify our office 72 hours in advance if you are unable to keep your appointment.</p>
														<p class=""><a href="https://maps.app.goo.gl/NE9SfbnjLK7JD3868" target="_blank">6490 Main Street, Suite 5, Williamsville, New York 14221</a></p>
														<p>Phone/SMS: <a href="tel:(716) 276-3553">(716) 276-3553</a> • Fax: <a href="fax:(716) 276-3552">(716) 276-3552</a> <br><a href="www.niagaraoms.com" target="_blank">www.niagaraoms.com</a></p>
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                var patient_phone_number = jQuery('#patient_phone_number').val();
                var date_of_birth = jQuery('#date_of_birth').val();
                var date_of_xray = jQuery('#date_of_xray').val();
                var referring_doctor_first_name = jQuery('#referring_doctor_first_name').val();
                var referring_doctor_last_name = jQuery('#referring_doctor_last_name').val();
				var referring_doctor_name = referring_doctor_first_name + ' ' + referring_doctor_last_name;
                var referring_doctor_phone_number = jQuery('#referring_doctor_phone_number').val();
                var diagnosis = jQuery('#diagnosis').val();
                var diagnosis_other = jQuery('#diagnosis_other').val();
                var permanent_teeth = jQuery('input[name="permanent_teeth[]"]:checked').map(function () {
		                return this.value;
		            }).get().join(', ');
                var primary_teeth = jQuery('input[name="primary_teeth[]"]:checked').map(function () {
		                return this.value;
		            }).get().join(', ');
                var is_3rd_moral_evaluation = jQuery('input[name="is_3rd_moral_evaluation"]:checked').val();
                var is_fill_arch_solution = jQuery('input[name="is_fill_arch_solution"]:checked').val();
                var is_implant_evaluation = jQuery('input[name="is_implant_evaluation"]:checked').val();
                var is_extractions_only = jQuery('input[name="is_extractions_only"]:checked').val();
                var is_expose_bond = jQuery('input[name="is_expose_bond"]:checked').val();
                var is_evaluate_for_grafting = jQuery('input[name="is_evaluate_for_grafting"]:checked').val();
                var is_pathology_evaluation = jQuery('input[name="is_pathology_evaluation"]:checked').val();
                var specify_lab = jQuery('#specify_lab').val();
                var traditional_impressions = jQuery('input[name="traditional_impressions"]:checked').val();
                var comments = jQuery('#comments').val();
			    var tag_name = 'referral-form';

			    form.validate({
			        rules: {
			            'first_name': {
			                required: true,
			            },
			            'last_name': {
			                required: true,
			            },
			            'patient_phone_number': {
			                required: true,
                			matches: true
			            },
			            'referring_doctor_first_name': {
			                required: true,
			            },
			            'referring_doctor_last_name': {
			                required: true,
			            },
			            'referring_doctor_phone_number': {
			                required: true,
                			matches: true
			            }
			        },
			        messages: {
			            'first_name': {
			                required: "Please enter Patient's First Name.",
			            },
			            'last_name': {
			                required: "Please enter Patient's Last Name.",
			            },
			            'patient_phone_number': {
			                required: "This field is required."
			            },
			            'referring_doctor_first_name': {
			                required: "Please enter Referring Doctor's First Name.",
			            },
			            'referring_doctor_last_name': {
			                required: "Please enter Referring Doctor's Last Name.",
			            },
			            'referring_doctor_phone_number': {
			                required: "This field is required."
			            }
			        }
			    });
			    if (form.valid() == true) {
			        jQuery.ajax({
			            type: "post",
			            url: "/code/add_referral_form.php",
			            data: formData,
			            beforeSend: function () {
			                jQuery('#submit_btn').prop('disabled', 'true');
			                jQuery('#submit_btn').html('processing<i class="fa fa-spinner fa-spin" style="font-size:24px;margin-left: 10px;"></i>');
			            },
			            success: function (data) {
			            	// console.log(data);
			            	var obj = jQuery.parseJSON(data);
			            	var fd={
			            	    firstName: first_name,
			            	    lastName: last_name,
			            	    name: first_name+' '+last_name,
			            	    phone: patient_phone_number,
			            	    "tags": [ tag_name ],
			            	    "customField":{
			            	        'AmeTrVWuBgawGxycZBZ9': date_of_birth,
			            	        'bcUYKG1hj7mPG7vDGtrJ': date_of_xray,
			            	        'uSpxXXp2uZLJEEIC90Sn': referring_doctor_name,
			            	        'uSpxXXp2uZLJEEIC90Sn': referring_doctor_first_name,
			            	        'yBuSH3eNGvjzCWX29hO5': referring_doctor_last_name,
			            	        'GhHV2MWgtrxyovGSy3Ze': referring_doctor_phone_number,
			            	        'tAgIr8Qah1N4KPEdz1R8': diagnosis,
			            	        'Vh3ALPAW7bxnbCLxq0XE': diagnosis_other,
			            	        'o7kSACzJjj6f1OMvAuUx': permanent_teeth,
			            	        '43XLVa2zBnBjQkWgbgrp': primary_teeth,
			            	        'mv3Aa6Irwe5Pfte9R0Ld': is_3rd_moral_evaluation,
			            	        'JlKOFfROCn4SSrBS1jmL': is_fill_arch_solution,
			            	        'lUVnzATRT4WKPRujRO1O': is_implant_evaluation,
			            	        'JDIIDYAteyieZyIyvhaL': is_extractions_only,
			            	        'fB3b07j8PVnhieJvcI9r': is_expose_bond,
			            	        '0KWw3eOFEvsvq0PExfkV': is_evaluate_for_grafting,
			            	        'ulkdg9M3Kai8xtbjbiCg': is_pathology_evaluation,
			            	        'x8ejgsw7fIcU4j2AoUAf': specify_lab,
			            	        'ukAmJUQhtK788zsewpoX': traditional_impressions,
			            	        'BYP0zl8hf0OXtJVWttLv': comments
			            	    }
			            	};
			            	// Niagara Dental Implant & Oral Surgery (Williamsville, NY) -- (GHL Account)
			            	var url = 'https://rest.gohighlevel.com/v1/contacts/';
			            	jQuery.ajax({
			            	    data: fd,
			            	    type: 'post',
			            	    url: url,
			            	    headers: {
			            	        Authorization: 'Bearer '+'eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJsb2NhdGlvbl9pZCI6InkyMUtDSFppS3dsb2lmZENlQmxyIiwidmVyc2lvbiI6MSwiaWF0IjoxNzUxMzMxNDIwMjI3LCJzdWIiOiJ1TUZ1UHV4QUNqaTNvc1MwaUFQMSJ9.y7PuKC6POx5WLhWJfuRZsTfZOoXJz1hPvCbh2buUzUU'
			            	    },
			            	    success: function(data) {
			            	        jQuery('.lbl_msg_success').show();
			            	        jQuery('.lbl_msg_success').html('Thank You for submitting.');
			            	        window.location.href = "/referral-thank-you.php?referral_id="+obj.referral_id;
			            	    }
			            	});                            
			            }
			        });
			    }
			});

		</script>
	</body>
</html>