{"id":1277,"date":"2026-01-20T01:40:05","date_gmt":"2026-01-20T01:40:05","guid":{"rendered":"https:\/\/smilogy.com.au\/aged-care\/?page_id=1277"},"modified":"2026-01-20T01:41:33","modified_gmt":"2026-01-20T01:41:33","slug":"individual-oral-health-assessment-consent-form","status":"publish","type":"page","link":"https:\/\/smilogy.com.au\/aged-care\/individual-oral-health-assessment-consent-form\/","title":{"rendered":"Individual Oral Health Assessment Consent Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1277\" class=\"elementor elementor-1277\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b197505 e-flex e-con-boxed e-con e-parent\" data-id=\"b197505\" 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-03d2c3e elementor-widget elementor-widget-shortcode\" data-id=\"03d2c3e\" 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-1267 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-1267\" data-uid=\"6a1c0765b5644\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-1267\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-1267 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=\"1267\"\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a1c0765b5644\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-1267--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1267--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=\"Resident 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_6a1c0765b5644\" id=\"forminator-field-name-2_6a1c0765b5644-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_6a1c0765b5644\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a1c0765b5644\" id=\"forminator-field-date-2-picker_6a1c0765b5644-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_6a1c0765b5644\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1920\" data-end-year=\"2026\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"01\/01\/1920\" data-end-date=\"2026-05-31\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a1c0765b5644\" id=\"forminator-field-name-1_6a1c0765b5644-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_6a1c0765b5644\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_6a1c0765b5644\" id=\"forminator-field-number-1_6a1c0765b5644-label\" class=\"forminator-label\">Room Number<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_6a1c0765b5644\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" \/><\/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-1267--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1267--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"Resident Information\"\n\t\t\t\tdata-actual-label=\"Veteran Affairs Information\"\n\t\t\t\tdata-name=\"page-break-4\"\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-1-6a1c0765b5644-label\"><span id=\"forminator-radiogroup-radio-1-6a1c0765b5644-label\" class=\"forminator-label\">Member of Veterans Affairs <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a1c0765b5644\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a1c0765b5644\" 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-1-2-6a1c0765b5644\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a1c0765b5644\" 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 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_6a1c0765b5644\" id=\"forminator-field-text-1_6a1c0765b5644-label\" class=\"forminator-label\">DVA Gold Card File Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a1c0765b5644\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/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-1267--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1267--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"Veteran Affairs Information\"\n\t\t\t\tdata-actual-label=\"Next of Kin \/ Authorised Representative\"\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=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_6a1c0765b5644\" id=\"forminator-field-name-3_6a1c0765b5644-label\" class=\"forminator-label\">Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_6a1c0765b5644\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a1c0765b5644\" id=\"forminator-field-phone-1_6a1c0765b5644-label\" class=\"forminator-label\">Contact Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a1c0765b5644\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a1c0765b5644\" id=\"forminator-field-email-1_6a1c0765b5644-label\" class=\"forminator-label\">Email Address<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a1c0765b5644\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" autocomplete=\"email\" \/><\/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-1267--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1267--page-3-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"3\"\n\t\t\t\tdata-label=\"Next of Kin \/ Authorised Representative\"\n\t\t\t\tdata-actual-label=\"Reason for Assessment\"\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=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a1c0765b5644\" id=\"forminator-field-textarea-1_6a1c0765b5644-label\" class=\"forminator-label\">What is your concern?<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a1c0765b5644\" class=\"forminator-textarea\" 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-1267--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-1267--page-4-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"4\"\n\t\t\t\tdata-label=\"Reason for Assessment\"\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_6a1c0765b5644\" id=\"forminator-field-consent-1_6a1c0765b5644-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_6a1c0765b5644__label\" class=\"forminator-checkbox forminator-consent\"><input type=\"checkbox\" name=\"consent-1\" id=\"forminator-field-consent-1_6a1c0765b5644\" value=\"checked\" aria-labelledby=\"forminator-field-consent-1_6a1c0765b5644-label\" aria-describedby=\"forminator-field-consent-1_6a1c0765b5644__description\" data-required=\"true\" aria-required=\"true\" \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><\/label><div id=\"forminator-field-consent-1_6a1c0765b5644__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_6a1c0765b5644\" id=\"forminator-field-name-4_6a1c0765b5644-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_6a1c0765b5644\" 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_6a1c0765b5644\" id=\"forminator-field-text-2_6a1c0765b5644-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_6a1c0765b5644\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-12 \"><label for=\"forminator-field-date-3\" id=\"forminator-field-date-3-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-3-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-1267__field--date-3-day_6a1c0765b5644\" id=\"forminator-field-1267__field--date-3-day_6a1c0765b5644-label\" class=\"forminator-label\">Day<\/label><select name=\"date-3-day\" id=\"forminator-field-1267__field--date-3-day_6a1c0765b5644\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-labelledby=\"forminator-field-1267__field--date-3-day_6a1c0765b5644-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">Select day<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-3-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-1267__field--date-3-month_6a1c0765b5644\" id=\"forminator-field-1267__field--date-3-month_6a1c0765b5644-label\" class=\"forminator-label\">Month<\/label><select name=\"date-3-month\" id=\"forminator-field-1267__field--date-3-month_6a1c0765b5644\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-labelledby=\"forminator-field-1267__field--date-3-month_6a1c0765b5644-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">Select month<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-3-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-1267__field--date-3-year_6a1c0765b5644\" id=\"forminator-field-1267__field--date-3-year_6a1c0765b5644-label\" class=\"forminator-label\">Year<\/label><select name=\"date-3-year\" id=\"forminator-field-1267__field--date-3-year_6a1c0765b5644\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-labelledby=\"forminator-field-1267__field--date-3-year_6a1c0765b5644-label\" data-default-value=\"2026\"><option value=\"\" >Select Year<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/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><div 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style=\"display: none;\" disabled>Submit<\/button><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"274fe406d7\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/aged-care\/wp-json\/wp\/v2\/pages\/1277\" \/><input type=\"hidden\" name=\"form_id\" value=\"1267\"><input type=\"hidden\" name=\"page_id\" value=\"1277\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/smilogy.com.au\/aged-care\/individual-oral-health-assessment-consent-form\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><label for=\"input_16\" class=\"forminator-hidden\" aria-hidden=\"true\">Please do not fill in this field. <input id=\"input_16\" type=\"text\" name=\"input_16\" value=\"\" autocomplete=\"off\"><\/label><\/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":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1277","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/pages\/1277","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=1277"}],"version-history":[{"count":7,"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/pages\/1277\/revisions"}],"predecessor-version":[{"id":1284,"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/pages\/1277\/revisions\/1284"}],"wp:attachment":[{"href":"https:\/\/smilogy.com.au\/aged-care\/wp-json\/wp\/v2\/media?parent=1277"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}