{"id":1207,"date":"2025-12-05T01:07:45","date_gmt":"2025-12-05T01:07:45","guid":{"rendered":"https:\/\/smilogy.com.au\/aged-care\/?page_id=1207"},"modified":"2026-01-20T01:57:44","modified_gmt":"2026-01-20T01:57:44","slug":"individual-booking","status":"publish","type":"page","link":"https:\/\/smilogy.com.au\/aged-care\/individual-booking\/","title":{"rendered":"Individual Booking"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1207\" class=\"elementor elementor-1207\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fe9ffca e-flex e-con-boxed e-con e-parent\" data-id=\"fe9ffca\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-505980f elementor-widget elementor-widget-heading\" data-id=\"505980f\" 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\">Individual Oral Assessment Request<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-731e0f6 elementor-widget elementor-widget-text-editor\" data-id=\"731e0f6\" 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>After you fill out this order request, Smilogy Aged Care will be in contact to let you know the date the assessments are booked. If you have any questions please contact us at 1300 247 867 or agedcare@smilogy.com.au<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-61b4a24 elementor-widget elementor-widget-shortcode\" data-id=\"61b4a24\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-1231 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1231\" data-uid=\"69f2e3d6b97c2\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1231\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1231 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"1231\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"69f2e3d6b97c2\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-pagination-progress\" aria-hidden=\"true\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-1231--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1231--page-0-label\"\n\t\t\t\tdata-step=\"0\"\n\t\t\t\tdata-label=\"Consent for Oral Health Assessment\"\n\t\t\t\tdata-actual-label=\"Information\"\n\t\t\t\tdata-name=\"page-break-1\"\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69f2e3d6b97c2\" id=\"forminator-field-name-2_69f2e3d6b97c2-label\" class=\"forminator-label\">Name of Resident <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69f2e3d6b97c2\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69f2e3d6b97c2\" id=\"forminator-field-name-1_69f2e3d6b97c2-label\" class=\"forminator-label\">Facility Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69f2e3d6b97c2\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-2-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-address_line_69f2e3d6b97c2\" id=\"forminator-field-address-2-address_line_69f2e3d6b97c2-label\" class=\"forminator-label\">Room Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_69f2e3d6b97c2\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69f2e3d6b97c2\" id=\"forminator-field-address-1-street_address_69f2e3d6b97c2-label\" class=\"forminator-label\">Address ( incl. Room no.) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_69f2e3d6b97c2\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69f2e3d6b97c2\" id=\"forminator-field-date-2-picker_69f2e3d6b97c2-label\" class=\"forminator-label\">Date of Birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69f2e3d6b97c2\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1960\" data-end-year=\"2026\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"01\/01\/1960\" data-end-date=\"2026-04-30\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69f2e3d6b97c2\" id=\"forminator-field-name-3_69f2e3d6b97c2-label\" class=\"forminator-label\">Next of Kin Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_69f2e3d6b97c2\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69f2e3d6b97c2\" id=\"forminator-field-phone-2_69f2e3d6b97c2-label\" class=\"forminator-label\">NOK Contact Phone no <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_69f2e3d6b97c2\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-national_mode=\"enabled\" data-country=\"au\" data-validation=\"standard\" \/><\/div><\/div><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_69f2e3d6b97c2\" id=\"forminator-field-email-2_69f2e3d6b97c2-label\" class=\"forminator-label\">NOK Contact Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"\" id=\"forminator-field-email-2_69f2e3d6b97c2\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69f2e3d6b97c2\" id=\"forminator-field-textarea-1_69f2e3d6b97c2-label\" class=\"forminator-label\">What is your concern?<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_69f2e3d6b97c2\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-1231--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1231--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"Information\"\n\t\t\t\tdata-actual-label=\"Department of Veteran Affairs\"\n\t\t\t\tdata-name=\"page-break-2\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-69f2e3d6b97c2-label\"><span id=\"forminator-radiogroup-radio-1-69f2e3d6b97c2-label\" class=\"forminator-label\">Do you have a DVA card? <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-1231--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1231--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"Department of Veteran Affairs\"\n\t\t\t\tdata-actual-label=\"DVA Card No.\"\n\t\t\t\tdata-name=\"page-break-3\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69f2e3d6b97c2\" id=\"forminator-field-text-1_69f2e3d6b97c2-label\" class=\"forminator-label\">DVA Card No. <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69f2e3d6b97c2\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-69f2e3d6b97c2-label\"><span id=\"forminator-radiogroup-radio-3-69f2e3d6b97c2-label\" class=\"forminator-label\">NSW Trustee &amp; Guardian <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-3-label-3\" for=\"forminator-field-radio-3-3-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"Unsure\"><input type=\"radio\" name=\"radio-3\" value=\"Unsure\" id=\"forminator-field-radio-3-3-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-3-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Unsure<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-69f2e3d6b97c2-label\"><span id=\"forminator-radiogroup-radio-4-69f2e3d6b97c2-label\" class=\"forminator-label\">NSW Trustee &amp; Guardian <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><label id=\"forminator-field-radio-4-label-3\" for=\"forminator-field-radio-4-3-69f2e3d6b97c2\" class=\"forminator-radio\" title=\"Unsure\"><input type=\"radio\" name=\"radio-4\" value=\"Unsure\" id=\"forminator-field-radio-4-3-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-radio-4-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Unsure<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69f2e3d6b97c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-69f2e3d6b97c2-label\" class=\"forminator-label\">Payment Details<\/span><label id=\"forminator-field-checkbox-1-1-69f2e3d6b97c2-label\" for=\"forminator-field-checkbox-1-1-69f2e3d6b97c2\" class=\"forminator-checkbox\" title=\"Individual Oral Assessment $75\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-checkbox-1-1-69f2e3d6b97c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Individual Oral Assessment $75<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-69f2e3d6b97c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-69f2e3d6b97c2-label\" class=\"forminator-label\">Payment Details<\/span><label id=\"forminator-field-checkbox-2-1-69f2e3d6b97c2-label\" for=\"forminator-field-checkbox-2-1-69f2e3d6b97c2\" class=\"forminator-checkbox\" title=\"Individual Oral Assessment $75\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-checkbox-2-1-69f2e3d6b97c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Individual Oral Assessment $75<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-69f2e3d6b97c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-69f2e3d6b97c2-label\" class=\"forminator-label\">Payment Details<\/span><label id=\"forminator-field-checkbox-3-1-69f2e3d6b97c2-label\" for=\"forminator-field-checkbox-3-1-69f2e3d6b97c2\" class=\"forminator-checkbox\" title=\"Individual Oral Assessment $75\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-checkbox-3-1-69f2e3d6b97c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Individual Oral Assessment $75<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-69f2e3d6b97c2-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-69f2e3d6b97c2-label\" class=\"forminator-label\">Payment Details<\/span><label id=\"forminator-field-checkbox-4-1-69f2e3d6b97c2-label\" for=\"forminator-field-checkbox-4-1-69f2e3d6b97c2\" class=\"forminator-checkbox\" title=\"Individual Oral Assessment $75\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-69f2e3d6b97c2\" aria-labelledby=\"forminator-field-checkbox-4-1-69f2e3d6b97c2-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Individual Oral Assessment $75<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-1231--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1231--page-3-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"3\"\n\t\t\t\tdata-label=\"DVA Card No.\"\n\t\t\t\tdata-actual-label=\"Consent for Oral Health Assessment\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"consent-1\" class=\"forminator-field-consent forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-consent-1_69f2e3d6b97c2\" id=\"forminator-field-consent-1_69f2e3d6b97c2-label\" class=\"forminator-label\">Consent for Oral Health Assessment <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-checkbox__wrapper\"><label id=\"forminator-field-consent-1_69f2e3d6b97c2__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_69f2e3d6b97c2\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_69f2e3d6b97c2-label\" aria-describedby=\"forminator-field-consent-1_69f2e3d6b97c2__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_69f2e3d6b97c2__description\" class=\"forminator-checkbox__label forminator-consent__label\"><p>I consent to Smilogy Aged Care conducting an oral health assessment for the resident named above. I understand that:<br>1. The assessment will be completed within the resident\u2019s<br>aged care facility.<br>2. A written report will outline findings and<br>recommendations.<br>3. Fees apply unless the resident holds a valid Veteran Affairs<br>Gold Card.<br>4. Additional treatment may involve extra costs.<br>5. Relevant information may be shared with facility staff.<\/p><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69f2e3d6b97c2\" id=\"forminator-field-name-4_69f2e3d6b97c2-label\" class=\"forminator-label\">Name of Person Giving Consent <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69f2e3d6b97c2\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69f2e3d6b97c2\" id=\"forminator-field-text-2_69f2e3d6b97c2-label\" class=\"forminator-label\">Relationship to Resident <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69f2e3d6b97c2\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"stripe-ocs-1\" class=\"forminator-field-stripe-ocs forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"stripe-ocs-1-field\" id=\"stripe-ocs-1-field-label\" class=\"forminator-label\">Credit \/ Debit Card <span class=\"forminator-required\">*<\/span><\/label><span id=\"payment-element-69f2e3d6b97c2-description\" class=\"forminator-description\">Amount to be charged: AUD $75<\/span><div id=\"payment-element-69f2e3d6b97c2\" data-elements-options=\"{\n    &quot;loader&quot;: &quot;always&quot;,\n    &quot;locale&quot;: &quot;auto&quot;,\n    &quot;paymentMethodCreation&quot;: &quot;manual&quot;,\n    &quot;appearance&quot;: {\n        &quot;theme&quot;: &quot;stripe&quot;,\n        &quot;variables&quot;: {\n            &quot;fontWeightNormal&quot;: &quot;400&quot;,\n            &quot;fontSizeBase&quot;: &quot;16px&quot;,\n            &quot;iconColor&quot;: &quot;#777771&quot;,\n            &quot;iconHoverColor&quot;: &quot;#097BAA&quot;,\n            &quot;iconCardErrorColor&quot;: &quot;#E51919&quot;,\n            &quot;iconCardCvcErrorColor&quot;: &quot;#E51919&quot;,\n            &quot;colorTextPlaceholder&quot;: &quot;#888888&quot;\n        }\n    }\n}\" data-payment-options=\"{\n    &quot;layout&quot;: {\n        &quot;type&quot;: &quot;tabs&quot;,\n        &quot;defaultCollapsed&quot;: false\n    }\n}\" data-field-id=\"69f2e3d6b97c2\" data-is-payment=\"true\" data-payment-type=\"stripe\" data-is-ocs=\"1\" data-secret=\"\" data-paymentid=\"\" data-currency=\"aud\" data-key=\"pk_test_51OZN8pLIQSEh6jFHhAngqUYLWWrj9mZTBqdzhRhsb1P71isFTmEg4z1ElHCVcK7leGz02Zj4LGLxIu7f6yOxTL2w00T6ptN9eX\" data-receipt=\"1\" data-receipt-email=\"email-1\" data-billing=\"1\" data-billing-name=\"name-2\" data-billing-email=\"email-1\" data-billing-phone=\"phone-2\" data-billing-address=\"address-1\" data-return-url=\"https:\/\/stripe.com\" aria-describedby=\"payment-element-69f2e3d6b97c2-description\" class=\"forminator-stripe-element forminator-stripe-payment-element\"><\/div><input type=\"hidden\" name=\"paymentid\" value=\"\" id=\"forminator-stripe-paymentid\"\/><input type=\"hidden\" name=\"paymentmethod\" value=\"\" id=\"forminator-stripe-paymentmethod\"\/><input type=\"hidden\" name=\"subscriptionid\" value=\"\" id=\"forminator-stripe-subscriptionid\"\/><span class=\"forminator-card-message\"><span class=\"forminator-error-message\" aria-hidden=\"true\"><\/span><\/span><\/div><\/div><\/div><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled>Submit<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"093c3d2eb1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/aged-care\/wp-json\/wp\/v2\/pages\/1207\" \/><input type=\"hidden\" name=\"form_id\" value=\"1231\"><input type=\"hidden\" name=\"page_id\" value=\"1207\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/smilogy.com.au\/aged-care\/individual-booking\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Individual Oral Assessment Request After you fill out this order request, Smilogy Aged Care will be in contact to let you know the date the assessments are booked. If you have any questions please contact us at 1300 247 867 or agedcare@smilogy.com.au<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1207","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/pages\/1207","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/comments?post=1207"}],"version-history":[{"count":15,"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/pages\/1207\/revisions"}],"predecessor-version":[{"id":1290,"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/pages\/1207\/revisions\/1290"}],"wp:attachment":[{"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/media?parent=1207"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}