{"id":1399,"date":"2021-08-12T13:18:23","date_gmt":"2021-08-12T13:18:23","guid":{"rendered":"https:\/\/www.duraanorthodontics.co.za\/eng\/?page_id=1399"},"modified":"2021-08-12T13:35:09","modified_gmt":"2021-08-12T13:35:09","slug":"referral-form","status":"publish","type":"page","link":"https:\/\/www.duraanorthodontics.co.za\/eng\/referral-form\/","title":{"rendered":"Referral Form"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-1 fusion-text-no-margin\" style=\"line-height:1;margin-top:0px;margin-right:0px;margin-bottom:0px;margin-left:0px;\"><h2>Referrals<\/h2>\n<\/div><div class=\"fusion-separator\" style=\"align-self: flex-start;margin-right:auto;margin-bottom:20px;width:100%;max-width:300px;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#f78c1d;border-top-width:6px;\"><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-0{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-0 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-0{width:50% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-0{width:100% !important;order : 0;}.fusion-builder-column-0 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_2_3 2_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-2\" style=\"line-height:1.5;margin-top:0px;\"><h6 class=\"fusion-responsive-typography-calculated\" style=\"--fontsize: 18; line-height: 1.5; --minfontsize: 18;\" data-fontsize=\"18\" data-lineheight=\"27px\">To refer a patient to us, please complete the below online form and submit it directly to us.<\/h6>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-1{width:66.666666666667% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-1 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 2.88%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 2.88%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-1{width:66.666666666667% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 2.88%;margin-left : 2.88%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><\/div><style type=\"text\/css\">.fusion-fullwidth.fusion-builder-row-1 a:not(.awb-custom-text-color):not(.fusion-button):not(.fusion-builder-module-control):not(.fusion-social-network-icon):not(.fb-icon-element):not(.fusion-countdown-link):not(.fusion-rollover-link):not(.fusion-rollover-gallery):not(.fusion-button-bar):not(.add_to_cart_button):not(.show_details_button):not(.product_type_external):not(.fusion-view-cart):not(.fusion-quick-view):not(.fusion-rollover-title-link):not(.fusion-breadcrumb-link) , .fusion-fullwidth.fusion-builder-row-1 a:not(.awb-custom-text-color):not(.fusion-button):not(.fusion-builder-module-control):not(.fusion-social-network-icon):not(.fb-icon-element):not(.fusion-countdown-link):not(.fusion-rollover-link):not(.fusion-rollover-gallery):not(.fusion-button-bar):not(.add_to_cart_button):not(.show_details_button):not(.product_type_external):not(.fusion-view-cart):not(.fusion-quick-view):not(.fusion-rollover-title-link):not(.fusion-breadcrumb-link):before, .fusion-fullwidth.fusion-builder-row-1 a:not(.awb-custom-text-color):not(.fusion-button):not(.fusion-builder-module-control):not(.fusion-social-network-icon):not(.fb-icon-element):not(.fusion-countdown-link):not(.fusion-rollover-link):not(.fusion-rollover-gallery):not(.fusion-button-bar):not(.add_to_cart_button):not(.show_details_button):not(.product_type_external):not(.fusion-view-cart):not(.fusion-quick-view):not(.fusion-rollover-title-link):not(.fusion-breadcrumb-link):after {color: #ff9412;}.fusion-fullwidth.fusion-builder-row-1 a:not(.awb-custom-text-hover-color):not(.fusion-button):not(.fusion-builder-module-control):not(.fusion-social-network-icon):not(.fb-icon-element):not(.fusion-countdown-link):not(.fusion-rollover-link):not(.fusion-rollover-gallery):not(.fusion-button-bar):not(.add_to_cart_button):not(.show_details_button):not(.product_type_external):not(.fusion-view-cart):not(.fusion-quick-view):not(.fusion-rollover-title-link):not(.fusion-breadcrumb-link):hover, .fusion-fullwidth.fusion-builder-row-1 a:not(.awb-custom-text-hover-color):not(.fusion-button):not(.fusion-builder-module-control):not(.fusion-social-network-icon):not(.fb-icon-element):not(.fusion-countdown-link):not(.fusion-rollover-link):not(.fusion-rollover-gallery):not(.fusion-button-bar):not(.add_to_cart_button):not(.show_details_button):not(.product_type_external):not(.fusion-view-cart):not(.fusion-quick-view):not(.fusion-rollover-title-link):not(.fusion-breadcrumb-link):hover:before, .fusion-fullwidth.fusion-builder-row-1 a:not(.awb-custom-text-hover-color):not(.fusion-button):not(.fusion-builder-module-control):not(.fusion-social-network-icon):not(.fb-icon-element):not(.fusion-countdown-link):not(.fusion-rollover-link):not(.fusion-rollover-gallery):not(.fusion-button-bar):not(.add_to_cart_button):not(.show_details_button):not(.product_type_external):not(.fusion-view-cart):not(.fusion-quick-view):not(.fusion-rollover-title-link):not(.fusion-breadcrumb-link):hover:after {color: #ffad49;}.fusion-fullwidth.fusion-builder-row-1 .pagination a.inactive:hover, .fusion-fullwidth.fusion-builder-row-1 .fusion-filters .fusion-filter.fusion-active a {border-color: #ffad49;}.fusion-fullwidth.fusion-builder-row-1 .pagination .current {border-color: #ffad49; background-color: #ffad49;}.fusion-fullwidth.fusion-builder-row-1 .fusion-filters .fusion-filter.fusion-active a, .fusion-fullwidth.fusion-builder-row-1 .fusion-date-and-formats .fusion-format-box, .fusion-fullwidth.fusion-builder-row-1 .fusion-popover, .fusion-fullwidth.fusion-builder-row-1 .tooltip-shortcode {color: #ffad49;}#wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .fusion-vertical-menu-widget .menu li.current_page_ancestor > a, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .fusion-vertical-menu-widget .menu li.current_page_ancestor > a:before, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .fusion-vertical-menu-widget .current-menu-item > a, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .fusion-vertical-menu-widget .current-menu-item > a:before, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .fusion-vertical-menu-widget .current_page_item > a, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .fusion-vertical-menu-widget .current_page_item > a:before {color: #ffad49;}#wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .widget_nav_menu .menu li.current_page_ancestor > a, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .widget_nav_menu .menu li.current_page_ancestor > a:before, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .widget_nav_menu .current-menu-item > a, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .widget_nav_menu .current-menu-item > a:before, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .widget_nav_menu .current_page_item > a, #wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .widget_nav_menu .current_page_item > a:before {color: #ffad49;}#wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-vertical-menu-widget .menu li.current_page_item > a { border-right-color:#ffad49;border-left-color:#ffad49;}#wrapper .fusion-fullwidth.fusion-builder-row-1 .fusion-widget-area .tagcloud a:hover { color: #fff; background-color: #ffad49;border-color: #ffad49;}#main .fusion-fullwidth.fusion-builder-row-1 .post .blog-shortcode-post-title a:hover {color: #ffad49;}.fusion-body .fusion-flex-container.fusion-builder-row-1{ padding-top : 0px;margin-top : 0px;padding-right : 0px;padding-bottom : 0px;margin-bottom : 0px;padding-left : 0px;}<\/style><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1248px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:10px;margin-bottom:10px;width:100%;\"><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-2{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-2 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_6 1_6 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-3{width:16.666666666667% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-3 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 11.52%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 11.52%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-3{width:16.666666666667% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 11.52%;margin-left : 11.52%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-3{width:100% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_2_3 2_3 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><style>.fusion-form-form-wrapper .fusion-form-1401 .fusion-form-tooltip .fusion-form-tooltip-content{color:#ffffff !important;background-color:#333333 !important;border-color:#333333 !important;}.fusion-form-form-wrapper .fusion-form-1401 .fusion-form-field{margin-top:5px;margin-bottom:5px;}<\/style><div class=\"fusion-form fusion-form-builder fusion-form-form-wrapper fusion-form-1401\" data-form-id=\"1401\" data-config=\"{&quot;form_id&quot;:&quot;1401&quot;,&quot;form_post_id&quot;:&quot;1401&quot;,&quot;post_id&quot;:1399,&quot;form_type&quot;:&quot;database_email&quot;,&quot;confirmation_type&quot;:&quot;message&quot;,&quot;redirect_url&quot;:&quot;&quot;,&quot;field_labels&quot;:{&quot;doctor_name&quot;:&quot;&quot;,&quot;practice_email_address&quot;:&quot;&quot;,&quot;practice_phone_number&quot;:&quot;&quot;,&quot;patient_name&quot;:&quot;&quot;,&quot;patient_email_address&quot;:&quot;&quot;,&quot;patient_phone_number&quot;:&quot;&quot;,&quot;patient_birthdate&quot;:&quot;&quot;,&quot;attachments&quot;:&quot;Attach files here:&quot;,&quot;message&quot;:&quot;&quot;},&quot;field_logics&quot;:{&quot;doctor_name&quot;:&quot;&quot;,&quot;practice_email_address&quot;:&quot;&quot;,&quot;practice_phone_number&quot;:&quot;&quot;,&quot;patient_name&quot;:&quot;&quot;,&quot;patient_email_address&quot;:&quot;&quot;,&quot;patient_phone_number&quot;:&quot;&quot;,&quot;patient_birthdate&quot;:&quot;&quot;,&quot;attachments&quot;:&quot;&quot;,&quot;message&quot;:&quot;&quot;}}\"><form action=\"https:\/\/www.duraanorthodontics.co.za\/eng\/referral-form\/\" method=\"post\" class=\"fusion-form fusion-form-1401\" enctype=\"multipart\/form-data\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#e2e2e2;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-3\"><h3>Referring Doctor's Details<\/h3>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-5{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1401\"><input type=\"text\" name=\"doctor_name\" id=\"doctor_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Referring Doctor&#039;s Name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"1401\"><div class=\"fusion-form-input-with-icon\"><i class=\"fa-envelope fas\"><\/i><input type=\"email\" name=\"practice_email_address\" id=\"practice_email_address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Practice Email Address*\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-6{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-6 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-6{width:50% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-phone-number-field fusion-form-label-above\" data-form-id=\"1401\"><div class=\"fusion-form-input-with-icon\"><i class=\"fa-phone fas\"><\/i><input type=\"phone-number\" name=\"practice_phone_number\" id=\"practice_phone_number\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Practice Phone Number\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-7{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-7 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-7{width:50% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 3.84%;margin-left : 3.84%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:5px;margin-bottom:5px;width:100%;\"><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-8{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-8 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-text fusion-text-4\"><h3>Patient Details<\/h3>\n<\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-9{width:100% !important;margin-top : 0px;margin-bottom : 20px;}.fusion-builder-column-9 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 1.92%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 1.92%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"1401\"><input type=\"text\" name=\"patient_name\" id=\"patient_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Patient&#039;s Name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"1401\"><div class=\"fusion-form-input-with-icon\"><i class=\"fa-envelope fas\"><\/i><input type=\"email\" name=\"patient_email_address\" id=\"patient_email_address\" value=\"\"  class=\"fusion-form-input\" required=\"true\" 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