{"id":3606,"date":"2025-10-29T12:05:36","date_gmt":"2025-10-29T16:05:36","guid":{"rendered":"https:\/\/cliniquemaxillo.com\/referrals\/"},"modified":"2026-02-11T19:37:22","modified_gmt":"2026-02-12T00:37:22","slug":"referrals","status":"publish","type":"page","link":"https:\/\/cliniquemaxillo.com\/en\/referrals\/","title":{"rendered":"Referrals"},"content":{"rendered":"    <section class=\"text-two-columns || section\">\n        \n<span class=\"absolute top-0 left-0\" ><\/span>        <div class=\"wrapper\">\n            <div class=\"lg:grid-col\">\n                <div class=\"lg:col-start-1 lg:col-span-6 xl:col-span-5\">\n                    <h2 class=\"text-h2 || max-lg:mb-6\">Committed to providing all our patients with the highest quality services in a comfortable environment<\/h2>\n                <\/div>\n                <div class=\"wysiwyg-container || lg:mt-10 lg:col-start-7 lg:col-span-6 xxl:mt-12\">\n    <p><span>If you are a healthcare professional wishing to send us a patient&#8217;s file so that we can evaluate and provide the care required for their condition, please complete the form below. The transmission of the information provided is encrypted to ensure the confidentiality of your patients.<\/span><\/p>\n<\/div>            <\/div>\n        <\/div>\n    <\/section>\n\n\n    <section class=\"form || section\">\n        \n<span class=\"absolute top-0 left-0\"  id=\"form\" ><\/span>        <div class=\"wrapper || lg:grid-col\">\n                        <div class=\"max-lg:mt-8 || lg:col-start-2 lg:col-span-10 xxl:col-start-3 xxl:col-span-8\">\n                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_2' style='display:none'><div id='gf_2' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_2' id='gform_2'  action='\/en\/wp-json\/wp\/v2\/pages\/3606#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_41\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_41'>Name<\/label><div class='ginput_container'><input name='input_41' id='input_2_41' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_2_41'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_2_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Patient Information<\/h3><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Name of the person being referred (first and last name)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='large'    placeholder='Name of the person being referred (first and last name)' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_2_4' type='tel' value='' class='large'  placeholder='Phone' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_2_5' type='email' value='' class='large'   placeholder='Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_2_6' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of Birth' aria-describedby=\"input_2_6_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_6_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_6' class='gform_hidden' value='https:\/\/cliniquemaxillo.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Referring Provider<\/h3><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Provider Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_2_8' type='text' value='' class='large'    placeholder='Provider Name' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_2_9' type='email' value='' class='large'   placeholder='Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Clinics<\/h3><\/div><fieldset id=\"field_2_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Clinic<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_11'>\n\t\t\t<div class='gchoice gchoice_2_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Montreal (Lachine)'  id='choice_2_11_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_0' id='label_2_11_0' class='gform-field-label gform-field-label--type-inline'>Montreal (Lachine)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='South Shore (Ste-Catherine)'  id='choice_2_11_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_1' id='label_2_11_1' class='gform-field-label gform-field-label--type-inline'>South Shore (Ste-Catherine)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='First Availability'  id='choice_2_11_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_11_2' id='label_2_11_2' class='gform-field-label gform-field-label--type-inline'>First Availability<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Specialists<\/h3><\/div><fieldset id=\"field_2_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Specialist<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_13'>\n\t\t\t<div class='gchoice gchoice_2_13_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Dr Mathieu Lenis'  id='choice_2_13_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_0' id='label_2_13_0' class='gform-field-label gform-field-label--type-inline'>Dr Mathieu Lenis<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='Dr Elliot Saleh'  id='choice_2_13_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_1' id='label_2_13_1' class='gform-field-label gform-field-label--type-inline'>Dr Elliot Saleh<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_13_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_13' type='radio' value='First Availability'  id='choice_2_13_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_13_2' id='label_2_13_2' class='gform-field-label gform-field-label--type-inline'>First Availability<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Appointment Scheduling<\/h3><\/div><fieldset id=\"field_2_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Appointment<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_15'>\n\t\t\t<div class='gchoice gchoice_2_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Please contact the patient'  id='choice_2_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_15_0' id='label_2_15_0' class='gform-field-label gform-field-label--type-inline'>Please contact the patient<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='The patient will contact you to schedule an appointment'  id='choice_2_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_15_1' id='label_2_15_1' class='gform-field-label gform-field-label--type-inline'>The patient will contact you to schedule an appointment<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_16\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Reason for Consultation<\/h3><\/div><fieldset id=\"field_2_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full raisons-consultation field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Reasons for Consultation<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_17'><div class='gchoice gchoice_2_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='Extractions'  id='choice_2_17_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_17_1' id='label_2_17_1' class='gform-field-label gform-field-label--type-inline'>Extractions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_17_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.2' type='checkbox'  value='Implants'  id='choice_2_17_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_17_2' id='label_2_17_2' class='gform-field-label gform-field-label--type-inline'>Implants<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_17_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.3' type='checkbox'  value='Malocclusion'  id='choice_2_17_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_17_3' id='label_2_17_3' class='gform-field-label gform-field-label--type-inline'>Malocclusion<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_17_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.4' type='checkbox'  value='TMJ'  id='choice_2_17_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_17_4' id='label_2_17_4' class='gform-field-label gform-field-label--type-inline'>TMJ<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_17_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.5' type='checkbox'  value='Biopsy'  id='choice_2_17_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_17_5' id='label_2_17_5' class='gform-field-label gform-field-label--type-inline'>Biopsy<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_17_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.6' type='checkbox'  value='Intravenous Sedation'  id='choice_2_17_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_17_6' id='label_2_17_6' class='gform-field-label gform-field-label--type-inline'>Intravenous Sedation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_17_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.7' type='checkbox'  value='Other'  id='choice_2_17_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_17_7' id='label_2_17_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Other required care:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full teeth-form-container gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"form-container\"><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full top-left gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"guide\">Right<\/div><fieldset id=\"field_2_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Top row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_21'><div class='gchoice gchoice_2_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='18'  id='choice_2_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_1' id='label_2_21_1' class='gform-field-label gform-field-label--type-inline'>18<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='17'  id='choice_2_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_2' id='label_2_21_2' class='gform-field-label gform-field-label--type-inline'>17<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='16'  id='choice_2_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_3' id='label_2_21_3' class='gform-field-label gform-field-label--type-inline'>16<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='15'  id='choice_2_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_4' id='label_2_21_4' class='gform-field-label gform-field-label--type-inline'>15<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='14'  id='choice_2_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_5' id='label_2_21_5' class='gform-field-label gform-field-label--type-inline'>14<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='13'  id='choice_2_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_6' id='label_2_21_6' class='gform-field-label gform-field-label--type-inline'>13<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.7' type='checkbox'  value='12'  id='choice_2_21_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_7' id='label_2_21_7' class='gform-field-label gform-field-label--type-inline'>12<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_21_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.8' type='checkbox'  value='11'  id='choice_2_21_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_21_8' id='label_2_21_8' class='gform-field-label gform-field-label--type-inline'>11<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_22\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Bottom row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_22'><div class='gchoice gchoice_2_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='55'  id='choice_2_22_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_1' id='label_2_22_1' class='gform-field-label gform-field-label--type-inline'>55<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='54'  id='choice_2_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_2' id='label_2_22_2' class='gform-field-label gform-field-label--type-inline'>54<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='53'  id='choice_2_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_3' id='label_2_22_3' class='gform-field-label gform-field-label--type-inline'>53<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.4' type='checkbox'  value='52'  id='choice_2_22_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_4' id='label_2_22_4' class='gform-field-label gform-field-label--type-inline'>52<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_22_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.5' type='checkbox'  value='51'  id='choice_2_22_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_22_5' id='label_2_22_5' class='gform-field-label gform-field-label--type-inline'>51<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_23\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full hide-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full top-right gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"guide\">Left<\/div><fieldset id=\"field_2_25\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Top row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_25'><div class='gchoice gchoice_2_25_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.1' type='checkbox'  value='21'  id='choice_2_25_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_1' id='label_2_25_1' class='gform-field-label gform-field-label--type-inline'>21<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.2' type='checkbox'  value='22'  id='choice_2_25_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_2' id='label_2_25_2' class='gform-field-label gform-field-label--type-inline'>22<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.3' type='checkbox'  value='23'  id='choice_2_25_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_3' id='label_2_25_3' class='gform-field-label gform-field-label--type-inline'>23<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.4' type='checkbox'  value='24'  id='choice_2_25_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_4' id='label_2_25_4' class='gform-field-label gform-field-label--type-inline'>24<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.5' type='checkbox'  value='25'  id='choice_2_25_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_5' id='label_2_25_5' class='gform-field-label gform-field-label--type-inline'>25<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.6' type='checkbox'  value='26'  id='choice_2_25_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_6' id='label_2_25_6' class='gform-field-label gform-field-label--type-inline'>26<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.7' type='checkbox'  value='27'  id='choice_2_25_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_7' id='label_2_25_7' class='gform-field-label gform-field-label--type-inline'>27<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_25_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_25.8' type='checkbox'  value='28'  id='choice_2_25_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_25_8' id='label_2_25_8' class='gform-field-label gform-field-label--type-inline'>28<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Bottom row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_26'><div class='gchoice gchoice_2_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='61'  id='choice_2_26_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>61<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='62'  id='choice_2_26_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_2' id='label_2_26_2' class='gform-field-label gform-field-label--type-inline'>62<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='63'  id='choice_2_26_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_3' id='label_2_26_3' class='gform-field-label gform-field-label--type-inline'>63<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='64'  id='choice_2_26_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_4' id='label_2_26_4' class='gform-field-label gform-field-label--type-inline'>64<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='65'  id='choice_2_26_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_26_5' id='label_2_26_5' class='gform-field-label gform-field-label--type-inline'>65<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_27\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full hide-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bottom-left gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"hide-html\"><\/div><fieldset id=\"field_2_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Top row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_30'><div class='gchoice gchoice_2_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='85'  id='choice_2_30_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_1' id='label_2_30_1' class='gform-field-label gform-field-label--type-inline'>85<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='84'  id='choice_2_30_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_2' id='label_2_30_2' class='gform-field-label gform-field-label--type-inline'>84<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='83'  id='choice_2_30_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_3' id='label_2_30_3' class='gform-field-label gform-field-label--type-inline'>83<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.4' type='checkbox'  value='82'  id='choice_2_30_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_4' id='label_2_30_4' class='gform-field-label gform-field-label--type-inline'>82<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_30_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.5' type='checkbox'  value='81'  id='choice_2_30_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_30_5' id='label_2_30_5' class='gform-field-label gform-field-label--type-inline'>81<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_29\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Bottom row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_29'><div class='gchoice gchoice_2_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='48'  id='choice_2_29_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_1' id='label_2_29_1' class='gform-field-label gform-field-label--type-inline'>48<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.2' type='checkbox'  value='47'  id='choice_2_29_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_2' id='label_2_29_2' class='gform-field-label gform-field-label--type-inline'>47<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.3' type='checkbox'  value='46'  id='choice_2_29_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_3' id='label_2_29_3' class='gform-field-label gform-field-label--type-inline'>46<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.4' type='checkbox'  value='45'  id='choice_2_29_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_4' id='label_2_29_4' class='gform-field-label gform-field-label--type-inline'>45<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.5' type='checkbox'  value='44'  id='choice_2_29_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_5' id='label_2_29_5' class='gform-field-label gform-field-label--type-inline'>44<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.6' type='checkbox'  value='43'  id='choice_2_29_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_6' id='label_2_29_6' class='gform-field-label gform-field-label--type-inline'>43<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.7' type='checkbox'  value='42'  id='choice_2_29_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_7' id='label_2_29_7' class='gform-field-label gform-field-label--type-inline'>42<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_29_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.8' type='checkbox'  value='41'  id='choice_2_29_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_29_8' id='label_2_29_8' class='gform-field-label gform-field-label--type-inline'>41<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_31\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full hide-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><\/div><div id=\"field_2_32\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full bottom-right gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"hide-html\"><\/div><fieldset id=\"field_2_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Top row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_33'><div class='gchoice gchoice_2_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='71'  id='choice_2_33_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_1' id='label_2_33_1' class='gform-field-label gform-field-label--type-inline'>71<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='72'  id='choice_2_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_2' id='label_2_33_2' class='gform-field-label gform-field-label--type-inline'>72<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='73'  id='choice_2_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_3' id='label_2_33_3' class='gform-field-label gform-field-label--type-inline'>73<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='74'  id='choice_2_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_4' id='label_2_33_4' class='gform-field-label gform-field-label--type-inline'>74<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_33_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.5' type='checkbox'  value='75'  id='choice_2_33_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_33_5' id='label_2_33_5' class='gform-field-label gform-field-label--type-inline'>75<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Bottom row<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_2_34'><div class='gchoice gchoice_2_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='31'  id='choice_2_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>31<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='32'  id='choice_2_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_2' id='label_2_34_2' class='gform-field-label gform-field-label--type-inline'>32<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='33'  id='choice_2_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_3' id='label_2_34_3' class='gform-field-label gform-field-label--type-inline'>33<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='34'  id='choice_2_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_4' id='label_2_34_4' class='gform-field-label gform-field-label--type-inline'>34<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_34_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.5' type='checkbox'  value='35'  id='choice_2_34_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_5' id='label_2_34_5' class='gform-field-label gform-field-label--type-inline'>35<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_34_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.6' type='checkbox'  value='36'  id='choice_2_34_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_6' id='label_2_34_6' class='gform-field-label gform-field-label--type-inline'>36<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_34_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.7' type='checkbox'  value='37'  id='choice_2_34_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_7' id='label_2_34_7' class='gform-field-label gform-field-label--type-inline'>37<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_34_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.8' type='checkbox'  value='38'  id='choice_2_34_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_34_8' id='label_2_34_8' class='gform-field-label gform-field-label--type-inline'>38<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_35\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full hide-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><\/div><div id=\"field_2_36\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full hide-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><\/div><div id=\"field_2_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'>Clinical Information<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='large'    placeholder='Clinical Information'  aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">X-rays<\/h3><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_2_39'>Upload if available<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_2_39' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_2_39&quot;,&quot;container&quot;:&quot;gform_multifile_upload_2_39&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_2_39&quot;,&quot;filelist&quot;:&quot;gform_preview_2_39&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/cliniquemaxillo.com\\\/en\\\/?gf_page=1ef277f9cb0b3cf&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/cliniquemaxillo.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/cliniquemaxillo.com\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:2,&quot;field_id&quot;:39,&quot;_gform_file_upload_nonce_2_39&quot;:&quot;a0ec5772ce&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_2_39&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_2_39' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_2_39' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_2_39\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_39'>Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_2_39'><\/ul> <div id='gform_preview_2_39' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_2_40\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'>Date of X-ray(s)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_40' id='input_2_40' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Date of X-ray(s)' aria-describedby=\"input_2_40_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_40_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_40' class='gform_hidden' value='https:\/\/cliniquemaxillo.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> \t\t<input\n\t\t\t\ttype=\"hidden\"\n\t\t\t\tclass=\"hcaptcha-widget-id\"\n\t\t\t\tname=\"hcaptcha-widget-id\"\n\t\t\t\tvalue=\"eyJzb3VyY2UiOlsiZ3Jhdml0eWZvcm1zXC9ncmF2aXR5Zm9ybXMucGhwIl0sImZvcm1faWQiOjJ9-f8e6e9b90b287b5e3c68bb6a8740a775\">\n\t\t\t\t<h-captcha\n\t\t\tclass=\"h-captcha\"\n\t\t\tdata-sitekey=\"13380004-2dcc-4562-a910-f40261e06f92\"\n\t\t\tdata-theme=\"light\"\n\t\t\tdata-size=\"invisible\"\n\t\t\tdata-auto=\"false\"\n\t\t\tdata-ajax=\"false\"\n\t\t\tdata-force=\"false\">\n\t\t<\/h-captcha>\n\t\t<input type=\"hidden\" id=\"gravity_forms_nonce\" name=\"gravity_forms_nonce\" value=\"7a1994d5f3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/3606\" \/>\t\t<label for=\"hcap_hp_epeqgypySVb1\"><\/label>\n\t\t<input\n\t\t\t\ttype=\"text\" id=\"hcap_hp_epeqgypySVb1\" name=\"hcap_hp_epeqgypySVb1\" value=\"\"\n\t\t\t\treadonly inputmode=\"none\" autocomplete=\"new-password\" tabindex=\"-1\" aria-hidden=\"true\"\n\t\t\t\tstyle=\"position:absolute; left:-9999px; top:auto; height:0; width:0; opacity:0;\"\/>\n\t\t<input type=\"hidden\" name=\"hcap_hp_sig\" value=\"ddf4e29be4\"\/>\n\t\t<input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=gravity-theme&amp;hash=3a2b18085ce1ae25fdd7663b03716fd6' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='' \/>\n            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Our surgeons&#8217; expertise allows us to manage a wide variety of conditions, from the most common to the most unusual.<\/p>\n<p>We leverage our expertise and know-how to offer your patients an optimal and reassuring care environment. Our approaches prioritize quality surgeries, maximum comfort, including the use of advanced technologies such as 3D radiology and virtual surgical planning.<\/p>\n<p>We also place great importance on personalized support, informed advice, and rigorous follow-up to ensure optimal recovery and successful treatments.<\/p>\n<p><a class=\"btn-primary\" href=\"https:\/\/cliniquemaxillo.com\/en\/about\/\" target=\"\"> <span>About the Clinic<\/span> <\/a><\/p>\n<\/div>            <\/div>\n            <div class=\"lg:col-start-1 mt-8 || lg:mt-0 lg:col-span-6 lg:row-start-1 xl:col-span-5\">\n                    <div class=\"thumbnail w-full \"\n        style=\"padding-bottom: 125.23364485981%\"\n    >\n\n\n    <img decoding=\"async\" width=\"1400\" height=\"1411\" data-src=\"https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-1400x1411.jpg\" alt=\"Module image\" data-srcset=\"https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-1400x1411.jpg 1400w, https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-1524x1536.jpg 1524w, https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-1024x1032.jpg 1024w, https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-640x645.jpg 640w, https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-480x484.jpg 480w, https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-350x353.jpg 350w, https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332-150x151.jpg 150w, https:\/\/cliniquemaxillo.com\/wp-content\/uploads\/2025\/10\/iStock-1143346309-1-1-scaled-e1770470318332.jpg 1694w\" data-sizes=\"(max-width: 1400px) 100vw, 1400px\" src=\"data:image\/svg+xml;base64,PHN2ZyB3aWR0aD0iMSIgaGVpZ2h0PSIxIiB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciPjwvc3ZnPg==\" class=\"lazyload\" style=\"--smush-placeholder-width: 1400px; 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