{"id":46042,"date":"2026-02-27T11:58:38","date_gmt":"2026-02-27T10:58:38","guid":{"rendered":"https:\/\/panadent.ch\/create-your-space-now\/"},"modified":"2026-02-27T11:58:46","modified_gmt":"2026-02-27T10:58:46","slug":"create-your-space-now","status":"publish","type":"page","link":"https:\/\/panadent.ch\/en\/create-your-space-now\/","title":{"rendered":"Create your space now"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"46042\" class=\"elementor elementor-46042 elementor-31820\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c8a4050 elementor-reverse-mobile elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"c8a4050\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-68d6e83\" data-id=\"68d6e83\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4bf0ffd elementor-widget__width-inherit elementor-widget elementor-widget-heading\" data-id=\"4bf0ffd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Create your space now<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3a0e0e3 elementor-widget elementor-widget-text-editor\" data-id=\"3a0e0e3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Enter your information online and everything will be ready when you arrive!<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4861de5 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4861de5\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f8e02fa\" data-id=\"f8e02fa\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-10b4034 elementor-widget elementor-widget-heading\" data-id=\"10b4034\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Registration<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0f2de9c elementor-widget__width-inherit elementor-widget elementor-widget-heading\" data-id=\"0f2de9c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Conventional visit<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6bbce1a elementor-button-align-start elementor-widget elementor-widget-form\" data-id=\"6bbce1a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"New Form\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"46042\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"6bbce1a\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Create your space now - PANADENT\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"46042\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ea7437e elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ea7437e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ea7437e]\" id=\"form-field-field_ea7437e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_813ebd4 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_813ebd4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_813ebd4]\" id=\"form-field-field_813ebd4\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_98d0576 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_98d0576\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tLocation\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_98d0576]\" id=\"form-field-field_98d0576\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_82e4632 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_82e4632\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_82e4632]\" id=\"form-field-field_82e4632\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f5d81d4 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f5d81d4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNPA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f5d81d4]\" id=\"form-field-field_f5d81d4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-cabinets elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-cabinets\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI would like to come to this office\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[cabinets]\" id=\"form-field-cabinets\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Domdidier\">Domdidier<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payerne\">Payerne<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yvonand\">Yvonand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Echallens\">Echallens<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riaz\">Riaz<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Le Landeron\">Le Landeron<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint-Blaise\">Saint-Blaise<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Boudry\">Boudry<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chaux-de-Fonds\">Chaux-de-Fonds<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bulle\">Bulle<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orbe\">Orbe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mies\">Mies<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Crans-pr\u00e8s-C\u00e9ligny\">Crans-pr\u00e8s-C\u00e9ligny<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint-Prex\">Saint-Prex<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gland\">Gland<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_52034a4 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_52034a4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel no.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_52034a4]\" id=\"form-field-field_52034a4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tE-mail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\" \" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_9716e32 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_9716e32]\" id=\"form-field-field_9716e32\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_9716e32\">I agree to be informed of the latest news available in the dental office (No obligation, can be cancelled at any time).<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6990a92 elementor-col-100\">\n\t\t\t\t\tIf I am a minor, please have my legal representative present:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0374a91 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0374a91\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0374a91]\" id=\"form-field-field_0374a91\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_13527c4 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_13527c4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirst name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_13527c4]\" id=\"form-field-field_13527c4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_3b793f2 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3b793f2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate of birth\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_3b793f2]\" id=\"form-field-field_3b793f2\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e174054 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e174054\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMy dental expenses are covered by :\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Myself\" id=\"form-field-field_e174054-0\" name=\"form_fields[field_e174054][]\"> <label for=\"form-field-field_e174054-0\">Myself<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"A social service\" id=\"form-field-field_e174054-1\" name=\"form_fields[field_e174054][]\"> <label for=\"form-field-field_e174054-1\">A social service<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ac6cecf elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ac6cecf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf it is a social service, what is its name?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ac6cecf]\" id=\"form-field-field_ac6cecf\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8b6aa01 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8b6aa01\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have supplemental dental insurance?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_8b6aa01-0\" name=\"form_fields[field_8b6aa01][]\"> <label for=\"form-field-field_8b6aa01-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_8b6aa01-1\" name=\"form_fields[field_8b6aa01][]\"> <label for=\"form-field-field_8b6aa01-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_050298a elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_050298a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, what is its name?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_050298a]\" id=\"form-field-field_050298a\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6e4cf06 elementor-col-100\">\n\t\t\t\t\tYour general health\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_80f12b7 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_80f12b7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you taking any medications?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_80f12b7-0\" name=\"form_fields[field_80f12b7][]\"> <label for=\"form-field-field_80f12b7-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_80f12b7-1\" name=\"form_fields[field_80f12b7][]\"> <label for=\"form-field-field_80f12b7-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_6fd406f elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6fd406f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, for:\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Blood\" id=\"form-field-field_6fd406f-0\" name=\"form_fields[field_6fd406f][]\"> <label for=\"form-field-field_6fd406f-0\">Blood<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Epilepsy \" id=\"form-field-field_6fd406f-1\" name=\"form_fields[field_6fd406f][]\"> <label for=\"form-field-field_6fd406f-1\">Epilepsy <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Bones \" id=\"form-field-field_6fd406f-2\" name=\"form_fields[field_6fd406f][]\"> <label for=\"form-field-field_6fd406f-2\">Bones <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-field_6fd406f-3\" name=\"form_fields[field_6fd406f][]\"> <label for=\"form-field-field_6fd406f-3\">Cancer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Autoimmune disease\" id=\"form-field-field_6fd406f-4\" name=\"form_fields[field_6fd406f][]\"> <label for=\"form-field-field_6fd406f-4\">Autoimmune disease<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_8d3f16b elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8d3f16b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have any allergies (latex, medication, other)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_8d3f16b-0\" name=\"form_fields[field_8d3f16b][]\"> <label for=\"form-field-field_8d3f16b-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_8d3f16b-1\" name=\"form_fields[field_8d3f16b][]\"> <label for=\"form-field-field_8d3f16b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c911af4 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c911af4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, which ones?  \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c911af4]\" id=\"form-field-field_c911af4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_753081e elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_753081e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you encountered a heart problem (heart valve, endocarditis, malformation, murmur)?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_753081e-0\" name=\"form_fields[field_753081e][]\"> <label for=\"form-field-field_753081e-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_753081e-1\" name=\"form_fields[field_753081e][]\"> <label for=\"form-field-field_753081e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a91fbb4 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a91fbb4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, which one?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a91fbb4]\" id=\"form-field-field_a91fbb4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_84f6b29 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_84f6b29\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you wear prosthetic material? (Plate, screws, pacemaker)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_84f6b29-0\" name=\"form_fields[field_84f6b29][]\"> <label for=\"form-field-field_84f6b29-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_84f6b29-1\" name=\"form_fields[field_84f6b29][]\"> <label for=\"form-field-field_84f6b29-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_351dc78 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_351dc78\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, since then:  \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Less than one year \" id=\"form-field-field_351dc78-0\" name=\"form_fields[field_351dc78][]\"> <label for=\"form-field-field_351dc78-0\">Less than one year <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"More than one year  \" id=\"form-field-field_351dc78-1\" name=\"form_fields[field_351dc78][]\"> <label for=\"form-field-field_351dc78-1\">More than one year  <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d933905 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d933905\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you suffer from diabetes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_d933905-0\" name=\"form_fields[field_d933905][]\"> <label for=\"form-field-field_d933905-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_d933905-1\" name=\"form_fields[field_d933905][]\"> <label for=\"form-field-field_d933905-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2603806 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2603806\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHave you had radio or chemotherapy?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes \" id=\"form-field-field_2603806-0\" name=\"form_fields[field_2603806][]\"> <label for=\"form-field-field_2603806-0\">Yes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2603806-1\" name=\"form_fields[field_2603806][]\"> <label for=\"form-field-field_2603806-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_29a16f4 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_29a16f4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf so, at what level?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_29a16f4]\" id=\"form-field-field_29a16f4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ccee1b8 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ccee1b8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhen will it happen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Right now\" id=\"form-field-field_ccee1b8-0\" name=\"form_fields[field_ccee1b8][]\"> <label for=\"form-field-field_ccee1b8-0\">Right now<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"In the past  \" id=\"form-field-field_ccee1b8-1\" name=\"form_fields[field_ccee1b8][]\"> <label for=\"form-field-field_ccee1b8-1\">In the past  <\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d42ab26 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d42ab26\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you pregnant?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_d42ab26-0\" name=\"form_fields[field_d42ab26][]\"> <label for=\"form-field-field_d42ab26-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_d42ab26-1\" name=\"form_fields[field_d42ab26][]\"> <label for=\"form-field-field_d42ab26-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1d420c1 elementor-col-100\">\n\t\t\t\t\tYour oral health  \t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_234d187 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_234d187\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow important is your oral health to you?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Large\" id=\"form-field-field_234d187-0\" name=\"form_fields[field_234d187][]\"> <label for=\"form-field-field_234d187-0\">Large<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Low\" id=\"form-field-field_234d187-1\" name=\"form_fields[field_234d187][]\"> <label for=\"form-field-field_234d187-1\">Low<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_e3a4082 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e3a4082\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tWhen was your last visit to the dentist?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"More than two years\" id=\"form-field-field_e3a4082-0\" name=\"form_fields[field_e3a4082][]\"> <label for=\"form-field-field_e3a4082-0\">More than two years<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"More than one year\" id=\"form-field-field_e3a4082-1\" name=\"form_fields[field_e3a4082][]\"> <label for=\"form-field-field_e3a4082-1\">More than one year<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"A few months\" id=\"form-field-field_e3a4082-2\" name=\"form_fields[field_e3a4082][]\"> <label for=\"form-field-field_e3a4082-2\">A few months<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_207ae82 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_207ae82\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have teeth that have broken in the past?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_207ae82-0\" name=\"form_fields[field_207ae82][]\"> <label for=\"form-field-field_207ae82-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_207ae82-1\" name=\"form_fields[field_207ae82][]\"> <label for=\"form-field-field_207ae82-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_918aaeb elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_918aaeb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDoes food get stuck between the teeth?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_918aaeb-0\" name=\"form_fields[field_918aaeb][]\"> <label for=\"form-field-field_918aaeb-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_918aaeb-1\" name=\"form_fields[field_918aaeb][]\"> <label for=\"form-field-field_918aaeb-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_ef1008b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ef1008b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAre you satisfied with the alignment of your teeth?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_ef1008b-0\" name=\"form_fields[field_ef1008b][]\"> <label for=\"form-field-field_ef1008b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_ef1008b-1\" name=\"form_fields[field_ef1008b][]\"> <label for=\"form-field-field_ef1008b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a6043fb elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6043fb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you like your smile?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_a6043fb-0\" name=\"form_fields[field_a6043fb][]\"> <label for=\"form-field-field_a6043fb-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_a6043fb-1\" name=\"form_fields[field_a6043fb][]\"> <label for=\"form-field-field_a6043fb-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cc383bf elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cc383bf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIf not, why not?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cc383bf]\" id=\"form-field-field_cc383bf\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_2fdcc9d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2fdcc9d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDo you have recurring pain or discomfort? (Tinnitus, headaches, shoulder\/knee pain, other)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yes\" id=\"form-field-field_2fdcc9d-0\" name=\"form_fields[field_2fdcc9d][]\"> <label for=\"form-field-field_2fdcc9d-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_2fdcc9d-1\" name=\"form_fields[field_2fdcc9d][]\"> <label for=\"form-field-field_2fdcc9d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b60e980 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b60e980\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHow did you find out about PanaDent?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Relations\" id=\"form-field-field_b60e980-0\" name=\"form_fields[field_b60e980][]\"> <label for=\"form-field-field_b60e980-0\">Relations<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Google\" id=\"form-field-field_b60e980-1\" name=\"form_fields[field_b60e980][]\"> <label for=\"form-field-field_b60e980-1\">Google<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Social networks\" id=\"form-field-field_b60e980-2\" name=\"form_fields[field_b60e980][]\"> <label for=\"form-field-field_b60e980-2\">Social networks<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_190dc9f elementor-col-100\">\n\t\t\t\t\tReasons for the consultation\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_359e851 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_359e851]\" id=\"form-field-field_359e851\" rows=\"5\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_00b04fe elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_00b04fe]\" id=\"form-field-field_00b04fe\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_00b04fe\">I authorize my treating dentist to transmit to any person, institution or other intervening party the data necessary for the realization of my treatment. I also authorize the transmission of data relating to the invoicing and collection of the fees due for the medical-dental services I have received (Caisse pour m\u00e9decin-dentistes SA and EOS Suisse SA). I agree to show up on time for consultations and to cancel an appointment at least 24 hours in advance, failing which I may be charged for it. Cancelled appointments are reasonably limited. PanaDent reserves the right to stop taking care of me in case of repeated breaches. We hope you enjoy your visit and remain at your disposal.  <\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_bf4d575 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_bf4d575]\" id=\"form-field-field_bf4d575\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_bf4d575\">By checking this box, I certify that all information provided is true and complete and agree to share it with PanaDent<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_5599ebd elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5599ebd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDate\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_5599ebd]\" id=\"form-field-field_5599ebd\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-recipient elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-recipient\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCabinet\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[recipient]\" id=\"form-field-recipient\" class=\"elementor-field-textual elementor-size-sm\">\n\t\t\t\t\t\t\t\t\t<option value=\"info@panadent.ch\">Domdidier<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"payerne@panadent.ch\">Payerne<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"yvonand@panadent.ch\">Yvonand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"echallens@panadent.ch\">Echallens<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"riaz@panadent.ch\">Riaz<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"landeron@panadent.ch\">Le Landeron<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"blaise@panadent.ch\">Saint-Blaise<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"boudry@panadent.ch\">Boudry<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"cdf@panadent.ch\">Chaux-de-Fonds<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"bulle@panadent.ch\">Bulle<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"orbe@panadent.ch\">Orbe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"mies@panadent.ch\">Mies<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"crans@panadent.ch\">Crans-pr\u00e8s-C\u00e9ligny<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"contact@lacotedentaire.ch\">Saint-Prex<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send \u27f6<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input\n                    class=\"apbct_special_field apbct_email_id__elementor_form\"\n                    name=\"apbct__email_id__elementor_form\"\n                    aria-label=\"apbct__label_id__elementor_form\"\n                    type=\"text\" size=\"30\" maxlength=\"200\" autocomplete=\"off\"\n                    value=\"\"\n                \/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d953f05 elementor-widget elementor-widget-html\" data-id=\"d953f05\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>jq2 = jQuery.noConflict();\r\njq2(function( $ ) {\r\n\r\n\r\n    \/\/ My dental expenses are covered by:\r\n    $('input[name=\"form_fields[field_e174054][]\"]').click(function () {\r\n        if ($('#form-field-field_e174054-1').is(':checked')) {\r\n            $('#form-field-field_ac6cecf').attr('required','required');\r\n        } else {\r\n            $(\"#form-field-field_ac6cecf\").removeAttr(\"required\");\r\n        }\r\n    });\r\n\r\n    \/\/ supplementary dental insurance\r\n    $('input[name=\"form_fields[field_8b6aa01][]\"]').click(function () {\r\n        if ($('#form-field-field_8b6aa01-0').is(':checked')) {\r\n            $('#form-field-field_050298a').attr('required','required');\r\n        } else {\r\n            $(\"#form-field-field_050298a\").removeAttr(\"required\");\r\n        }\r\n    });\r\n\r\n    \/\/ Do you have any allergies\r\n    $('input[name=\"form_fields[field_8d3f16b][]\"]').click(function () {\r\n        if ($('#form-field-field_8d3f16b-0').is(':checked')) {\r\n            $('#form-field-field_c911af4').attr('required','required');\r\n        } else {\r\n            $(\"#form-field-field_c911af4\").removeAttr(\"required\");\r\n        }\r\n    });\r\n\r\n    \/\/ Have you had a heart problem\r\n    $('input[name=\"form_fields[field_753081e][]\"]').click(function () {\r\n        if ($('#form-field-field_753081e-0').is(':checked')) {\r\n            $('#form-field-field_a91fbb4').attr('required','required');\r\n        } else {\r\n            $(\"#form-field-field_a91fbb4\").removeAttr(\"required\");\r\n        }\r\n    });\r\n\r\n    \/\/ Have you had radio or chemotherapy?\r\n    $('input[name=\"form_fields[field_2603806][]\"]').click(function () {\r\n        if ($('#form-field-field_2603806-0').is(':checked')) {\r\n            $('#form-field-field_29a16f4').attr('required','required');\r\n        } else {\r\n            $(\"#form-field-field_29a16f4\").removeAttr(\"required\");\r\n        }\r\n    });\r\n\r\n    \/\/ Do you like your smile?\r\n    $('input[name=\"form_fields[field_ef1008b][]\"]').click(function () {\r\n        if ($('#form-field-field_ef1008b-0').is(':checked')) {\r\n            $('#form-field-field_cc383bf').attr('required','required');\r\n        } else {\r\n            $(\"#form-field-field_cc383bf\").removeAttr(\"required\");\r\n        }\r\n    });\r\n\r\n    \/\/ Do you take medication?\r\n    $('input[name=\"form_fields[field_80f12b7][]\"]').click(function () {\r\n        if ($('#form-field-field_80f12b7-0').is(':checked')) {\r\n\r\n            dytm_checked = $('input[name=\"form_fields[field_6fd406f][]\"]:checked').length;\r\n\r\n            if(!dytm_checked) {\r\n                $('#form-field-field_6fd406f-0').attr('required','required');\r\n            } else {\r\n                $(\"#form-field-field_6fd406f-0\").removeAttr(\"required\");    \r\n            }\r\n        } else {\r\n            $(\"#form-field-field_6fd406f-0\").removeAttr(\"required\");\r\n        }\r\n    });\r\n    $('input[name=\"form_fields[field_6fd406f][]\"]').click(function () {\r\n        \r\n        dytm_checked = $('input[name=\"form_fields[field_6fd406f][]\"]:checked').length;\r\n\r\n        if(!dytm_checked && $('#form-field-field_80f12b7-0').is(':checked') ) {\r\n            $('#form-field-field_6fd406f-0').attr('required','required');\r\n        } else {\r\n            $(\"#form-field-field_6fd406f-0\").removeAttr(\"required\");    \r\n        }\r\n    });\r\n\r\n    \/\/ Do you wear prosthetic material?\r\n    $('input[name=\"form_fields[field_84f6b29][]\"]').click(function () {\r\n        if ($('#form-field-field_84f6b29-0').is(':checked')) {\r\n\r\n            dywpm_checked = $('input[name=\"form_fields[field_351dc78][]\"]:checked').length;\r\n\r\n            if(!dywpm_checked) {\r\n                $('#form-field-field_351dc78-0').attr('required','required');\r\n            } else {\r\n                $(\"#form-field-field_351dc78-0\").removeAttr(\"required\");    \r\n            }\r\n        } else {\r\n            $(\"#form-field-field_351dc78-0\").removeAttr(\"required\");\r\n        }\r\n    });\r\n    $('input[name=\"form_fields[field_351dc78][]\"]').click(function () {\r\n        \r\n        dywpm_checked = $('input[name=\"form_fields[field_351dc78][]\"]:checked').length;\r\n\r\n        if(!dywpm_checked && $('#form-field-field_84f6b29-0').is(':checked') ) {\r\n            $('#form-field-field_351dc78-0').attr('required','required');\r\n   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});\r\n});\r\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Enter your information online and everything will be ready when you arrive! Registration Conventional visit<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-46042","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Create your space now - PANADENT<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/panadent.ch\/en\/create-your-space-now\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Create your space now - PANADENT\" \/>\n<meta property=\"og:description\" content=\"Enter your information online and everything will be ready when you arrive! 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