{"id":1864,"date":"2023-11-24T16:05:46","date_gmt":"2023-11-24T16:05:46","guid":{"rendered":"https:\/\/mapledentalsf.ca\/?page_id=1864"},"modified":"2025-09-10T08:30:42","modified_gmt":"2025-09-10T12:30:42","slug":"forms","status":"publish","type":"page","link":"https:\/\/mapledentalsf.ca\/?page_id=1864","title":{"rendered":"X-Ray Release Form"},"content":{"rendered":"\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading has-text-align-center\">X-Ray Release Form<\/h2>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"has-text-align-center has-base-2-color has-custom-color-1-background-color has-text-color has-background has-link-color wp-elements-1 wp-block-paragraph\" style=\"border-width:14px;font-size:clamp(0.929rem, 0.929rem + ((1vw - 0.2rem) * 1.108), 1.4rem);\">At this time, we are not accepting new patients. Please only complete this form if you&#8217;ve been asked to by our staff. If you are an existing patient, please contact the office at (613) 283-6870 to update your information.<\/p>\n\n\n\n<div style=\"height:30px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<script>\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 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gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F1864' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fill'><div id=\"field_1_22\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"><label id='gfield_label_1_22' class='gfield_label gform-field-label' for='input_1_22'><span class='gform-field-label__text'>Company<\/span><\/label><div class='ginput_container'><input name='input_22' id='input_1_22' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_22'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"04f4fa24\" data-field-span=\"12\"><legend id='gfield_label_1_1' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Patient Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     aria-labelledby=\"input_1_1_3_label gfield_label_1_1\"\/>\n                                                    <label for='input_1_1_3' id='input_1_1_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' id='input_1_1_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ab1a4b9a\" data-field-span=\"6\"><label id='gfield_label_1_3' class='gfield_label gform-field-label' for='input_1_3'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_1_3'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_3'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_3' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_3' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_3' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"ab1a4b9a\" data-field-span=\"6\"><label id='gfield_label_1_21' class='gfield_label gform-field-label' for='input_1_21'><span class='gform-field-label__text'>Patient Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_1_21' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_1_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\" data-group-id=\"cac3de88\" data-field-span=\"6\"><label id='gfield_label_1_18' class='gfield_label gform-field-label' for='input_1_18'><span class='gform-field-label__text'>Previous Dental Office<\/span><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_1_18' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_19\" 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\" data-group-id=\"cac3de88\" data-field-span=\"6\"><label id='gfield_label_1_19' class='gfield_label gform-field-label' for='input_1_19'><span class='gform-field-label__text'>Dentist&#039;s Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_1_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"216b7d1f\" data-field-span=\"12\"><label id='gfield_label_1_20' class='gfield_label gform-field-label' for='input_1_20'><span class='gform-field-label__text'>Office Phone Number<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_1_20' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><fieldset id=\"field_1_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"bfd47c50\" data-field-span=\"12\"><legend id='gfield_label_1_4' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are there any other family members that you would like to include in this release form?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_4'>\n\t\t\t<div class='gchoice gchoice_1_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Yes'  id='choice_1_4_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_1_4_0 gfield_label_1_4\"   \/>\n\t\t\t\t\t<label for='choice_1_4_0' id='label_1_4_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='No'  id='choice_1_4_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_1_4_1' id='label_1_4_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_5\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a0ed30fe\" data-field-span=\"6\"><legend id='gfield_label_1_5' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Patient Name 1<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_5'>\n                            \n                            <span id='input_1_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_1_5_3' value=''   aria-required='true'     aria-labelledby=\"input_1_5_3_label gfield_label_1_5\"\/>\n                                                    <label for='input_1_5_3' id='input_1_5_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_1_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_5_6' id='input_1_5_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_7\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"a0ed30fe\" data-field-span=\"6\"><label id='gfield_label_1_7' class='gfield_label gform-field-label' for='input_1_7'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_1_7'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_7'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_7' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_7' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_7' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_1_6\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"25c4b643\" data-field-span=\"6\"><legend id='gfield_label_1_6' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Patient Name 2<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_6'>\n                            \n                            <span id='input_1_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.3' id='input_1_6_3' value=''   aria-required='false'     aria-labelledby=\"input_1_6_3_label gfield_label_1_6\"\/>\n                                                    <label for='input_1_6_3' id='input_1_6_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.6' id='input_1_6_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_6_6' id='input_1_6_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"25c4b643\" data-field-span=\"6\"><label id='gfield_label_1_8' class='gfield_label gform-field-label' for='input_1_8'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_1_8'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_8'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_8' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_8' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_8' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9fc11d2f\" data-field-span=\"6\"><legend id='gfield_label_1_9' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Patient Name 3<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_9'>\n                            \n                            <span id='input_1_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_1_9_3' value=''   aria-required='false'     aria-labelledby=\"input_1_9_3_label gfield_label_1_9\"\/>\n                                                    <label for='input_1_9_3' id='input_1_9_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_1_9_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_9_6' id='input_1_9_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"9fc11d2f\" data-field-span=\"6\"><label id='gfield_label_1_10' class='gfield_label gform-field-label' for='input_1_10'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_1_10'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_10'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_10' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_10' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_10' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_1_11\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"7e19ad6c\" data-field-span=\"6\"><legend id='gfield_label_1_11' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Patient Name 4<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_11'>\n                            \n                            <span id='input_1_11_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_11.3' id='input_1_11_3' value=''   aria-required='false'     aria-labelledby=\"input_1_11_3_label gfield_label_1_11\"\/>\n                                                    <label for='input_1_11_3' id='input_1_11_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_11_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_11.6' id='input_1_11_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_11_6' id='input_1_11_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"7e19ad6c\" data-field-span=\"6\"><label id='gfield_label_1_12' class='gfield_label gform-field-label' for='input_1_12'><span class='gform-field-label__text'>Date of Birth<\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/yyyy'\n\t\t\t\t\tid='input_1_12'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_12'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\t\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_12' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_12' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_12' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_1_16\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"0577fc48\" data-field-span=\"12\"><legend id='gfield_label_1_16' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_16.1' id='input_1_16_1' type='checkbox' value='1'   aria-labelledby=\"input_1_16_1_label gfield_label_1_16\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label id='input_1_16_1_label' class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_16_1' ><span class='gform-field-label__text'>I authorize you to release dental x-rays of all the above mentioned patients to Maple Dental via mail 24 Main St. W., Smiths Falls, Ontario K7A 1M5 or email admin@mapledentalsf.ca<\/span><\/label><input type='hidden' name='input_16.2' value='I authorize you to release dental x-rays of all the above mentioned patients to Maple Dental via mail 24 Main St. W., Smiths Falls, Ontario K7A 1M5 or email admin@mapledentalsf.ca' class='gform_hidden' \/><input type='hidden' name='input_16.3' value='1' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_1_15\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"18272aa9\" data-field-span=\"12\"><legend id='gfield_label_1_15' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Signature<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_15' id='input_1_15_signature_filename' class='gfield_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_1_15_Container' class='gfield_signature_container' style='height:90px; width:600px; ' ><input type='hidden' id='input_1_15_data' name='input_1_15_data' class='gfield_signature_data' \/><canvas id=\"input_1_15\" width=\"600\" height=\"90\" style=\"border-style: solid; border-width: 1px; border-color: #757575; background-color:#FFFFFF; cursor: url(https:\/\/mapledentalsf.ca\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><input type='text' id='input_1_15_textinput' name='input_1_15_textinput' class='gfield_signature_text_input' style='text-indent:10px;display:none;width:600px;height:90px;border-style:solid;border-width:1px;border-color:#757575;background-color:#FFFFFF;font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive;font-size:2em;padding:0 12px;box-sizing:border-box;color:#000000;' placeholder='Type your signature' autocomplete='off' aria-label='Type your signature' \/><style type='text\/css'>\n                #input_1_15_textinput::placeholder {\n                    font-size: 1.5rem;\n                    font-family: Arial;\n                    opacity: 0.8;\n                }\n            <\/style><\/div><div id='input_1_15_toolbar' class='gfield_signature_toolbar' dir='ltr' style='margin:5px 0;position:relative;height:35px;width:600px;max-width:100%;display:flex;align-items:center;'><div id='input_1_15_status' class='gfield_signature_status gform-visually-hidden' role='status' aria-live='polite' aria-atomic='true' style='position:absolute;width:1px;height:1px;padding:0;margin:-1px;overflow:hidden;clip:rect(0,0,0,0);white-space:nowrap;border:0;'><\/div><input type='hidden' id='input_1_15_font_select' class='gfield_signature_font_select' value='script' \/><div id='input_1_15_font_dropdown' class='gfield_signature_font_dropdown'><span class='gform-common-icon gform-common-icon--chevron-down gfield_signature_font_dropdown_icon'><\/span><button type='button' id='input_1_15_font_select_button' class='gfield_signature_font_select_button gform-theme__disable' tabindex='0' aria-haspopup='listbox' aria-expanded='false' aria-label='Font Options' style='width:100%;box-sizing:border-box;overflow:hidden;text-overflow:ellipsis;white-space:nowrap;font-family:\"Snell Roundhand\", \"Segoe Script\", cursive;color:#000000'>Your Name<\/button><ul id='input_1_15_font_select_list' class='gfield_signature_font_select_list' role='listbox' tabindex='-1' style='display:none;position:absolute;top:100%;left:0;right:0;margin:0;padding:0;list-style:none;background:#fff;border:1px solid #ccc;z-index:10;max-height:200px;overflow-y:auto;box-sizing:border-box;'><li class='gfield_signature_font_option' role='option' data-value='script' tabindex='0' style='font-family:&quot;Snell Roundhand&quot;, &quot;Segoe Script&quot;, cursive; color:#000000' aria-label='Your Name, Script style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='handwritten' tabindex='0' style='font-family:&quot;Bradley Hand&quot;, &quot;Comic Sans MS&quot;, cursive; color:#000000' aria-label='Your Name, Handwritten style'>Your Name<\/li><li class='gfield_signature_font_option' role='option' data-value='print' tabindex='0' style='font-family:&quot;Noteworthy&quot;, &quot;Segoe Print&quot;, cursive; color:#000000' aria-label='Your Name, Print style'>Your Name<\/li><\/ul><\/div><div class='gfield_signature_toolbar_icons' style='margin-left:auto;display:flex;align-items:center;'><button type='button' id='input_1_15_textbutton' class='gform-common-icon gform-common-icon--text-field gfield_signature_text_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Text Signature' aria-label='Text Signature'><\/button><button type='button' id='input_1_15_drawbutton' class='gform-common-icon gform-common-icon--pencil gfield_signature_draw_button gform-theme-no-framework' tabindex='0' style='display:none;background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Draw Signature' aria-label='Draw Signature'><\/button><button type='button' id='input_1_15_resetbutton' class='gform-common-icon gform-common-icon--arrow-path gfield_signature_reset_button gform-theme-no-framework' tabindex='0' style='background:none;border:0;padding:0;margin:0;appearance:none;-webkit-appearance:none;cursor:pointer;' alt='Clear Signature' aria-label='Clear Signature'><\/button><\/div><\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_1' class='gform_button button gform-button--width-full' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Submit<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='{&quot;inputPrimaryColor&quot;:&quot;#b44843&quot;,&quot;buttonPrimaryBackgroundColor&quot;:&quot;#b44843&quot;,&quot;buttonPrimaryColor&quot;:&quot;#e9e0d3&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='2B4p\/oSJb3LKuxY1+8XprgQuN0Jsd7uViNND7d3KBVQUSenl8sjLbWThv242L1uuNd2gqQF05WgiDtGSfCgccboXXejNgyHLgspgCm05RRiiC50=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/form>\n                        <\/div>","protected":false},"excerpt":{"rendered":"<p>X-Ray Release Form At this time, we are not accepting new patients. Please only complete this form if you&#8217;ve been asked to by our staff. 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