{"id":4595,"date":"2022-06-20T12:10:59","date_gmt":"2022-06-20T11:10:59","guid":{"rendered":"https:\/\/laboratoriojulianaandre.pt\/request-form\/"},"modified":"2022-06-20T12:12:40","modified_gmt":"2022-06-20T11:12:40","slug":"request-form","status":"publish","type":"page","link":"https:\/\/laboratoriojulianaandre.pt\/en\/request-form\/","title":{"rendered":"Request Form"},"content":{"rendered":"<section id=\"bt_bb_section6a05c820663dd\" class=\"bt_bb_section bt_bb_layout_boxed_1200 bt_bb_vertical_align_top bt_bb_top_spacing_normal\"  data-bt-override-class=\"null\"><div class=\"bt_bb_port\"><div class=\"bt_bb_cell\"><div class=\"bt_bb_cell_inner\"><div class=\"bt_bb_row \"  data-bt-override-class=\"{}\"><div class=\"bt_bb_row_holder\" ><div  class=\"bt_bb_column col-xxl-12 col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_vertical_align_top bt_bb_align_left bt_bb_padding_normal\"  data-width=\"12\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><div class=\"bt_bb_contact_form_7\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4594-o1\" lang=\"pt-PT\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/4595#wpcf7-f4594-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formul\u00e1rio de contacto\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4594\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"pt_PT\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4594-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p><label> Clinic<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-clinic-name\"><input size=\"40\" maxlength=\"80\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-clinic-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Dr.<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-doctor-name\"><input size=\"40\" maxlength=\"80\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-doctor-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Patient's Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"80\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> E-mail<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"80\" 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=\"your-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Age<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-age\"><input size=\"40\" maxlength=\"80\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-age\" \/><\/span> <\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-gender\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Male<\/span><input type=\"checkbox\" name=\"checkbox-gender\" value=\"Male\" \/><\/label><\/span><span class=\"wpcf7-list-item\"><label><span class=\"wpcf7-list-item-label\">Female<\/span><input type=\"checkbox\" name=\"checkbox-gender\" value=\"Female\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Other<\/span><input type=\"checkbox\" name=\"checkbox-gender\" value=\"Other\" \/><\/label><\/span><\/span><\/span>\n<\/p>\n<p><label> Scale<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-scale\"><input size=\"40\" maxlength=\"80\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-scale\" \/><\/span> <\/label>\n<\/p>\n<p><label> Tooth Colour<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-color\"><input size=\"40\" maxlength=\"80\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-color\" \/><\/span> <\/label>\n<\/p>\n<p><label> Type of work<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-work-type-message\"><textarea cols=\"40\" rows=\"10\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-work-type-message\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label><br \/>\nIf the work is Implantology, we need to know:<br \/>\n- Description of the implant(s) (Brand, platform...)<br \/>\n- Inform if the clinic sends components or if the laboratory makes the order<br \/>\nImplantology - information on the implant(s)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-message\"><textarea cols=\"40\" rows=\"10\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-message\"><\/textarea><\/span> <\/label>\n<\/p>\n<p><label> Photographic protocol:<br \/>\n- colour scale<br \/>\n- standing, facing with relaxed smile<br \/>\n- standing, facing with spontaneous smile<br \/>\n- standing in profile<br \/>\n<\/label>\n<\/p>\n<p><label> Sending protocol:<br \/>\n- Sending STL(s): upper, lower, articulation<br \/>\n- if available, send provisional STL<br \/>\n<\/label>\n<\/p>\n<p>Attach files:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-100\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file-100\" \/><\/span>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"acceptance-929\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"acceptance-929\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">By contacting the Juliana Andr\u00e9 Laboratory, I accept the processing of personal data in accordance with the <a href='\/en\/privacy-policy'>Privacy Policies<\/a>.<\/span><\/label><\/span><\/span><\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"10\"\/><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n\/* ]]> *\/\n<\/script>\n<\/p><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div><div class=\"bt_bb_row \"  data-bt-override-class=\"{}\"><div class=\"bt_bb_row_holder\" ><div  class=\"bt_bb_column col-xxl-12 col-xl-12 col-xs-12 col-sm-12 col-md-12 col-lg-12 bt_bb_vertical_align_top bt_bb_align_left bt_bb_padding_normal\"  data-width=\"12\" data-bt-override-class=\"{}\"><div class=\"bt_bb_column_content\"><\/div><\/div><\/div><\/div><\/div><!-- cell_inner --><\/div><!-- cell --><\/div><!-- port --><\/section>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/pages\/4595"}],"collection":[{"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/comments?post=4595"}],"version-history":[{"count":2,"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/pages\/4595\/revisions"}],"predecessor-version":[{"id":4597,"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/pages\/4595\/revisions\/4597"}],"wp:attachment":[{"href":"https:\/\/laboratoriojulianaandre.pt\/en\/wp-json\/wp\/v2\/media?parent=4595"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}