{"id":15343,"date":"2025-05-22T11:49:16","date_gmt":"2025-05-22T10:49:16","guid":{"rendered":"https:\/\/banningdental.co.uk\/referral\/?page_id=15343"},"modified":"2025-05-22T11:59:16","modified_gmt":"2025-05-22T10:59:16","slug":"dental-referrals","status":"publish","type":"page","link":"https:\/\/banningdental.co.uk\/referral\/","title":{"rendered":"Dental Referrals"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"15343\" class=\"elementor elementor-15343\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1d3e836 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"1d3e836\" data-element_type=\"section\">\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-8f58261\" data-id=\"8f58261\" data-element_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-4340510 elementor-widget elementor-widget-heading\" data-id=\"4340510\" data-element_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\">Banning Dental referral form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9836668 elementor-widget elementor-widget-shortcode\" data-id=\"9836668\" data-element_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='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ff-form-has-steps ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Referral Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='15343' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"23489ea137\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/referral\/wp-json\/wp\/v2\/pages\/15343\" \/><div class='ff-step-container' data-name=\"step_start-3_8\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div class='ff-step-header'><div class='ff-el-progress-status' aria-live='polite'><\/div>\n            <div class='ff-el-progress'>\n                <div role='progressbar'  class='ff-el-progress-bar'><span><\/span><\/div>\n            <\/div>\n            <ul style='display: none' class='ff-el-progress-title'>\n                <li>Referring Dentist Details<\/li><li>Patient Details<\/li>\n            <\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"fluentform-step active\" data-name=\"step_start-3_8\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" data-animation_type=\"slide\" ><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' >Practice Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_last_name_' >Dentist Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_3_names_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_phone' aria-label=\"Your contact number\">Your contact number<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone\" id=\"ff_3_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><p style=\"text-align: center\">We are sending confirmation emails after receiving a submission, please also check your SPAM.<\/p>\n<div class=\"notranslate\">\u00a0<\/div><\/div><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><button style='float: right;'  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Next<\/button><\/div><\/div><div style='display: none;' class=\" fluentform-step\" data-name=\"form_step-3_2\" ><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_3\" ><p><strong>To avoid any delay with your referral, please check that all details are correctly filled in before sending us the form!<\/strong><\/p><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_dropdown' aria-label=\"Title\">Title<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_3_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\">Please Select<\/option><option value=\"Mrs.\"  >Mrs.<\/option><option value=\"Ms.\"  >Ms.<\/option><option value=\"Miss\"  >Miss<\/option><option value=\"Mr.\"  >Mr.<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_1_first_name_' >Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_3_names_1_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_datetime' aria-label=\"Date of birth\">Date of birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_3_datetime\" class=\"ff-el-form-control ff-el-datepicker\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_phone_1' aria-label=\"Phone number\">Phone number<\/label><\/div><div class='ff-el-input--content'><input name=\"phone_1\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_1\" id=\"ff_3_phone_1\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_email_1' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_1\" id=\"ff_3_email_1\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_1' aria-label=\"Postal code\">Postal code<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_4\" ><p><strong>SECTION 1<\/strong>: Previous treatments<\/p>\n<hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Has the patient had any treatment with us before?\">Has the patient had any treatment with us before?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_a445b8cda0aadfb83f66d9674deb599f><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_a445b8cda0aadfb83f66d9674deb599f' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3bdbee356964bd55baa5fd29d9ea111b><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_3bdbee356964bd55baa5fd29d9ea111b' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_5\" ><hr \/>\n<p>&nbsp;<\/p>\n<p><strong>SECTION 2<\/strong>: What referral treatment are you referring the patient for?<\/p>\n<hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Treatment Requested\">Treatment Requested<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2958fff21b192c0fbd529f3fd392ed06><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Periodontics\"  id='checkbox_2958fff21b192c0fbd529f3fd392ed06' aria-label='Periodontics' aria-invalid='false' aria-required=true> <span>Periodontics<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_221393e0dcec1e01f7a4f4a5770862f2><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Prosthodontics\"  id='checkbox_221393e0dcec1e01f7a4f4a5770862f2' aria-label='Prosthodontics' aria-invalid='false' aria-required=true> <span>Prosthodontics<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_b166b070c2d9ea7c1bccdde9c675bf42><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Endodontics\"  id='checkbox_b166b070c2d9ea7c1bccdde9c675bf42' aria-label='Endodontics' aria-invalid='false' aria-required=true> <span>Endodontics<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1a3ab96200901f8e9989a2c211775732><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Implants\"  id='checkbox_1a3ab96200901f8e9989a2c211775732' aria-label='Implants' aria-invalid='false' aria-required=true> <span>Implants<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_71d792c4050348ff995d8f82dfec8ea6><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"OPG\"  id='checkbox_71d792c4050348ff995d8f82dfec8ea6' aria-label='OPG' aria-invalid='false' aria-required=true> <span>OPG<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5d3f4f2ed8a88abdb6cb88f7f0e655fa><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oral Medicine\"  id='checkbox_5d3f4f2ed8a88abdb6cb88f7f0e655fa' aria-label='Oral Medicine' aria-invalid='false' aria-required=true> <span>Oral Medicine<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_d323ca3cc289349ef935bf39a71979df><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Composite Bonding\"  id='checkbox_d323ca3cc289349ef935bf39a71979df' aria-label='Composite Bonding' aria-invalid='false' aria-required=true> <span>Composite Bonding<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_be09c21592347ffe26c09caaac75108c><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Facial Rejuvenation\"  id='checkbox_be09c21592347ffe26c09caaac75108c' aria-label='Facial Rejuvenation' aria-invalid='false' aria-required=true> <span>Facial Rejuvenation<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_00ec9bc7c455672bea65522010fa32b9><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Orthodontics\"  id='checkbox_00ec9bc7c455672bea65522010fa32b9' aria-label='Orthodontics' aria-invalid='false' aria-required=true> <span>Orthodontics<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2e43c1f44bc3ab5529e46b860e03a59b><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Oral Surgery\"  id='checkbox_2e43c1f44bc3ab5529e46b860e03a59b' aria-label='Oral Surgery' aria-invalid='false' aria-required=true> <span>Oral Surgery<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_31bfde5a38675212b5f05d952b2d6874><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"CBCT\"  id='checkbox_31bfde5a38675212b5f05d952b2d6874' aria-label='CBCT' aria-invalid='false' aria-required=true> <span>CBCT<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_e641a7bba3b5069591370e4728a2a031><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Sedation\"  id='checkbox_e641a7bba3b5069591370e4728a2a031' aria-label='Sedation' aria-invalid='false' aria-required=true> <span>Sedation<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_eed585bd1912f8363a0ca6f0424cee1a><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other\"  id='checkbox_eed585bd1912f8363a0ca6f0424cee1a' aria-label='Other' aria-invalid='false' aria-required=true> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_6\" ><hr \/>\n<p>&nbsp;<\/p>\n<p><strong>SECTION 3<\/strong>: If you are referring your patient for OPG or CBCT, please note that we require a justification for exposure. Please note that we are unable to report of the Xrays and it remains your responsibility to do so.<\/p>\n<hr \/><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_2' aria-label=\"Add your comments here:\">Add your comments here:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_3_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_7\" ><hr \/>\n<p>&nbsp;<\/p>\n<p><strong>SECTION 4<\/strong>: If you are referring your patient for treatment with our Endodontist or Oral Surgeon, please note that you must provide xrays (either as apical xrays or OPG)<\/p>\n<hr \/>\n<p>Any X-rays or relevant attachments<\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_file-upload_1' aria-label=\"File Upload\">File Upload<\/label><\/div><div class='ff-el-input--content'><label for='ff_3_file-upload_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload\" id=\"ff_3_file-upload_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_file-upload_3_1' aria-label=\"File Upload\">File Upload<\/label><\/div><div class='ff-el-input--content'><label for='ff_3_file-upload_3_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload_3\" id=\"ff_3_file-upload_3_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload_3\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_file-upload_2_1' aria-label=\"File Upload\">File Upload<\/label><\/div><div class='ff-el-input--content'><label for='ff_3_file-upload_2_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload_2\" id=\"ff_3_file-upload_2_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload_2\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_file-upload_1_1' aria-label=\"File Upload\">File Upload<\/label><\/div><div class='ff-el-input--content'><label for='ff_3_file-upload_1_1' class='ff_file_upload_holder'><span class='ff_upload_btn ff-btn' tabindex='0'>Choose File<\/span> <input type=\"file\" name=\"file-upload_1\" id=\"ff_3_file-upload_1_1\" class=\"ff-el-form-control  ff-screen-reader-element\" data-name=\"file-upload_1\" multiple=\"1\"  aria-invalid='false' aria-required=false><\/label><\/div><\/div>        <div class=\"ff-step-t-container ff-inner_submit_container ff-column-container ff_columns_total_2\">\n            <div class=\"ff-t-cell ff-t-column-1\"><div class='step-nav ff_step_nav_last'><button style='float: left;'  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Previous<\/button><\/div><\/div>\n            <div class=\"ff-t-cell ff-t-column-2\">\n                <div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Send<\/button><\/div>            <\/div>\n        <\/div>\n        <\/div><\/div><\/div>\n        <\/fieldset><\/form><div id='fluentform_3_errors' class='ff-errors-in-stack ff_form_instance_3_1 ff-form-loading_errors 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