{"id":302,"date":"2022-11-29T20:32:58","date_gmt":"2022-11-29T20:32:58","guid":{"rendered":"https:\/\/www.nekdental.com\/?page_id=302"},"modified":"2022-11-29T20:32:58","modified_gmt":"2022-11-29T20:32:58","slug":"appointment-booking","status":"publish","type":"page","link":"https:\/\/www.nekdental.com\/?page_id=302","title":{"rendered":"Appointment Booking"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-293\"><form id=\"wpforms-form-293\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"293\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F302\" data-token=\"981b873f4aa9cbc7c4bbde6a9eb54885\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-293-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_0\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-293-field_0\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][0][first]\" required><label for=\"wpforms-293-field_0\" class=\"wpforms-field-sublabel after \">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-293-field_0-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][0][last]\" required><label for=\"wpforms-293-field_0-last\" class=\"wpforms-field-sublabel after \">Last<\/label><\/div><\/div><div class=\"wpforms-field-description\">(Legal name for documents and insurance processing)<\/div><\/div><div id=\"wpforms-293-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_14\">Nickname \/ Preferred Name<\/label><input type=\"text\" id=\"wpforms-293-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><div class=\"wpforms-field-description\">(Which name would you like us to call you?)<\/div><\/div><div id=\"wpforms-293-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_1\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-293-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" required><\/div><div id=\"wpforms-293-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_15\">Phone Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-293-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" required><div class=\"wpforms-field-description\">(Please include area code)<\/div><\/div><div id=\"wpforms-293-field_9-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_9\">Can your above phone number exchange text messages directly with the dentist? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-293-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-293-field_9_1\" name=\"wpforms[fields][9]\" value=\"Yes\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_9_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-293-field_9_2\" name=\"wpforms[fields][9]\" value=\"No\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_9_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-293-field_8-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_8\">Which Dental Insurance do you need to process? <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-293-field_8\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-293-field_8_1\" name=\"wpforms[fields][8]\" value=\"No Insurance \/ Fee for Service Patient\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_8_1\">No Insurance \/ Fee for Service Patient<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-293-field_8_2\" name=\"wpforms[fields][8]\" value=\"Delta Dental\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_8_2\">Delta Dental<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-293-field_8_3\" name=\"wpforms[fields][8]\" value=\"Medicaid \/ Green Mountain Care\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_8_3\">Medicaid \/ Green Mountain Care<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-293-field_8_4\" name=\"wpforms[fields][8]\" value=\"Other Insurance\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_8_4\">Other Insurance<\/label><\/li><\/ul><\/div><div id=\"wpforms-293-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_10\">Dental Insurance Number<\/label><input type=\"text\" id=\"wpforms-293-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" ><div class=\"wpforms-field-description\">(Providing this information will allow for faster processing)<\/div><\/div><div id=\"wpforms-293-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_11\">Date of Birth<\/label><input type=\"text\" id=\"wpforms-293-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" ><div class=\"wpforms-field-description\">(This will allow us to check your insurance eligibility and coverage)<\/div><\/div><div id=\"wpforms-293-field_12-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_12\">Are you experiencing any of these problems?<\/label><ul id=\"wpforms-293-field_12\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_1\" name=\"wpforms[fields][12][]\" value=\"Pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_1\">Pain<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_2\" name=\"wpforms[fields][12][]\" value=\"Infection\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_2\">Infection<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_3\" name=\"wpforms[fields][12][]\" value=\"Broken tooth\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_3\">Broken tooth<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_4\" name=\"wpforms[fields][12][]\" value=\"Decay \/ Cavities\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_4\">Decay \/ Cavities<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_5\" name=\"wpforms[fields][12][]\" value=\"Esthetic \/ Cosmetic Issue\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_5\">Esthetic \/ Cosmetic Issue<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_6\" name=\"wpforms[fields][12][]\" value=\"Concerned generally about dentition\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_6\">Concerned generally about dentition<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_7\" name=\"wpforms[fields][12][]\" value=\"Have not seen a dentist in a long time\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_7\">Have not seen a dentist in a long time<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_12_8\" name=\"wpforms[fields][12][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_12_8\">Other<\/label><\/li><\/ul><div class=\"wpforms-field-description\">(Check all that apply)<\/div><\/div><div id=\"wpforms-293-field_13-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_13\">Do you think you already know which treatment you may need?<\/label><ul id=\"wpforms-293-field_13\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_1\" name=\"wpforms[fields][13][]\" value=\"Extraction\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_1\">Extraction<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_2\" name=\"wpforms[fields][13][]\" value=\"Filling\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_2\">Filling<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_5\" name=\"wpforms[fields][13][]\" value=\"Crown\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_5\">Crown<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_3\" name=\"wpforms[fields][13][]\" value=\"Root Canal\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_3\">Root Canal<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_6\" name=\"wpforms[fields][13][]\" value=\"Denture adjustment\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_6\">Denture adjustment<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_7\" name=\"wpforms[fields][13][]\" value=\"General exam and evaluation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_7\">General exam and evaluation<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_8\" name=\"wpforms[fields][13][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_8\">Other<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_13_4\" name=\"wpforms[fields][13][]\" value=\"Not sure\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_13_4\">Not sure<\/label><\/li><\/ul><div class=\"wpforms-field-description\">(Check all that apply)<\/div><\/div><div id=\"wpforms-293-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_16\">Which town are you located in?<\/label><input type=\"text\" id=\"wpforms-293-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/div><div id=\"wpforms-293-field_17-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_17\">Which appointment times do you prefer <\/label><ul id=\"wpforms-293-field_17\"><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_17_2\" name=\"wpforms[fields][17][]\" value=\"Daytime\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_17_2\">Daytime<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_17_4\" name=\"wpforms[fields][17][]\" value=\"Late Afternoon\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_17_4\">Late Afternoon<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_17_3\" name=\"wpforms[fields][17][]\" value=\"Evening\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_17_3\">Evening<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-293-field_17_1\" name=\"wpforms[fields][17][]\" value=\"Weekend\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-293-field_17_1\">Weekend<\/label><\/li><\/ul><div class=\"wpforms-field-description\">(Check all that apply)<\/div><\/div><div id=\"wpforms-293-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_18\">Where did you hear about our office?<\/label><input type=\"text\" id=\"wpforms-293-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/div><div id=\"wpforms-293-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-293-field_2\">Description of your dental concern \/ Your message<\/label><textarea id=\"wpforms-293-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/textarea><\/div><\/div><div class=\"wpforms-submit-container\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"293\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-293\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img src=\"https:\/\/www.nekdental.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.nekdental.com\/index.php?rest_route=\/wp\/v2\/pages\/302"}],"collection":[{"href":"https:\/\/www.nekdental.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.nekdental.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.nekdental.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nekdental.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=302"}],"version-history":[{"count":1,"href":"https:\/\/www.nekdental.com\/index.php?rest_route=\/wp\/v2\/pages\/302\/revisions"}],"predecessor-version":[{"id":304,"href":"https:\/\/www.nekdental.com\/index.php?rest_route=\/wp\/v2\/pages\/302\/revisions\/304"}],"wp:attachment":[{"href":"https:\/\/www.nekdental.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=302"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}