{"id":4210,"date":"2021-02-24T18:51:55","date_gmt":"2021-02-24T15:21:55","guid":{"rendered":"http:\/\/persian-health.com\/?page_id=4210"},"modified":"2021-02-24T18:51:57","modified_gmt":"2021-02-24T15:21:57","slug":"orthodontics-form","status":"publish","type":"page","link":"https:\/\/medical1.persian-health.com\/en\/orthodontics-form\/","title":{"rendered":"Orthodontics form"},"content":{"rendered":"\n\t<div id=\"gap-1380562149\" class=\"gap-element clearfix\" style=\"display:block; height:auto;\">\n\t\t\n<style>\n#gap-1380562149 {\n  padding-top: 30px;\n}\n<\/style>\n\t<\/div>\n\t\n\n<div class=\"container section-title-container\" ><h3 class=\"section-title section-title-center\"><b><\/b><span class=\"section-title-main\" style=\"color:rgb(61, 0, 87);\">Orthodontics application form<\/span><b><\/b><\/h3><\/div>\n\n<div class=\"row align-equal align-right\"  id=\"row-756268590\">\n\n\n\t<div id=\"col-618834054\" class=\"col medium-2 small-12 large-2\"  >\n\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n\n\n\t\t<\/div>\n\t\t\t<\/div>\n\n\t\n\n\t<div id=\"col-1357923832\" class=\"col medium-8 small-12 large-8\"  >\n\t\t<div class=\"col-inner text-left\"  >\n\t\t\t\n\t\t\t\n\n<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f4206-o1\" lang=\"fa-IR\" dir=\"rtl\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/4210#wpcf7-f4206-o1\" method=\"post\" class=\"wpcf7-form init\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4206\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.4\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fa_IR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4206-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<p><label> *First Name<br \/>\n    <span class=\"wpcf7-form-control-wrap First-name\"><input type=\"text\" name=\"First-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> *last Name<br \/>\n   <span class=\"wpcf7-form-control-wrap last-name\"><input type=\"text\" name=\"last-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> *Date of birth<br \/>\n    <span class=\"wpcf7-form-control-wrap birth\"><input type=\"date\" name=\"birth\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Sex<br \/>\n     <span class=\"wpcf7-form-control-wrap radio-35\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-35\" value=\"rather not say\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">rather not say<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"radio-35\" value=\"female\" \/><span class=\"wpcf7-list-item-label\">female<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-35\" value=\"male\" \/><span class=\"wpcf7-list-item-label\">male<\/span><\/label><\/span><\/span><\/span><\/label><\/p>\n<p><label> *country<br \/>\n    <span class=\"wpcf7-form-control-wrap country\"><input type=\"text\" name=\"country\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> *City<br \/>\n    <span class=\"wpcf7-form-control-wrap City\"><input type=\"text\" name=\"City\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> Address<br \/>\n    <span class=\"wpcf7-form-control-wrap Address\"><textarea name=\"Address\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span> <\/label><\/p>\n<p><label> *Mobile Phone Number<br \/>\n  <span class=\"wpcf7-form-control-wrap MobilePhoneNumber\"><input type=\"tel\" name=\"MobilePhoneNumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/label><\/p>\n<p><label> Phone Number<br \/>\n    <span class=\"wpcf7-form-control-wrap Phone\"><input type=\"tel\" name=\"Phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"+983130000000\" \/><\/span><\/label><\/p>\n<p><label> *Email<br \/>\n<span class=\"wpcf7-form-control-wrap email-153\"><input type=\"email\" name=\"email-153\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label> Discription of your request and problem<br \/>\n    <span class=\"wpcf7-form-control-wrap Description\"><textarea name=\"Description\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span> <\/label><\/p>\n<p><label> Please browe your medication document<br \/>\n<span class=\"wpcf7-form-control-wrap file-631\"><input type=\"file\" name=\"file-631\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.ppt,.pptx,.odt,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg,.wav,.wmv\" aria-invalid=\"false\" \/><\/span><span class=\"wpcf7-form-control-wrap file-916\"><input type=\"file\" name=\"file-916\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.ppt,.pptx,.odt,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg,.wav,.wmv\" aria-invalid=\"false\" \/><\/span><span class=\"wpcf7-form-control-wrap file-915\"><input type=\"file\" name=\"file-915\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf,.doc,.docx,.ppt,.pptx,.odt,.avi,.ogg,.m4a,.mov,.mp3,.mp4,.mpg,.wav,.wmv\" aria-invalid=\"false\" \/><\/span> <\/label><\/p>\n<p><label>?Which method do you prefer for communication <span class=\"wpcf7-form-control-wrap radio-505\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"radio-505\" value=\"WhatsApp\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">WhatsApp<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"radio-505\" value=\"Email\" \/><span class=\"wpcf7-list-item-label\">Email<\/span><\/label><\/span><\/span><\/span><\/label><\/p>\n<p><input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n\n\n\t\t<\/div>\n\t\t\t<\/div>\n\n\t\n\n\t<div id=\"col-1495051092\" class=\"col medium-2 small-12 large-2\"  >\n\t\t<div class=\"col-inner\"  >\n\t\t\t\n\t\t\t\n\n\n\t\t<\/div>\n\t\t\t<\/div>\n\n\t\n\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-blank.php","meta":{"footnotes":""},"class_list":["post-4210","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v16.1.1 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ 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