{"id":62,"date":"2024-08-14T20:04:31","date_gmt":"2024-08-14T20:04:31","guid":{"rendered":"https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/?page_id=62"},"modified":"2024-08-21T14:06:45","modified_gmt":"2024-08-21T21:06:45","slug":"contact-your-dentist-in-tijuana","status":"publish","type":"page","link":"https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/welcome\/top-rated-dentists-in-tijuana\/contact-your-dentist-in-tijuana\/","title":{"rendered":"Contact Your Dentist in Tijuana"},"content":{"rendered":"\n<p>Welcome to <strong>Beauty Smile Dental Studio<\/strong>, your trusted <strong>dentists in Tijuana.<\/strong> We&#8217;re here to provide you with exceptional dental care and support for all your needs. Whether you&#8217;re interested in scheduling an appointment, requesting an online consultation, starting your insurance preapproval, or sharing your feedback through our satisfaction survey, we&#8217;re here to assist you every step of the way.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large is-style-rounded\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"448\" src=\"https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Dental-Insurance-acceptance-in-tijuana-1024x448.jpg\" alt=\"Image showing a completed dental insurance form, exemplifying our streamlined process for dental tourism in Tijuana. Trust our expert dentists in Tijuana at Beauty Smile Dental Studio, your premier dental clinic in Tijuana\" class=\"wp-image-336\" srcset=\"https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Dental-Insurance-acceptance-in-tijuana-1024x448.jpg 1024w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Dental-Insurance-acceptance-in-tijuana-300x131.jpg 300w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Dental-Insurance-acceptance-in-tijuana-768x336.jpg 768w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Dental-Insurance-acceptance-in-tijuana-1536x672.jpg 1536w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Dental-Insurance-acceptance-in-tijuana.jpg 1600w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><figcaption class=\"wp-element-caption\"><br>Want to get in touch? Fill out the form below to contact us at Beauty Smile Dental Studio. We&#8217;re here to assist with all your dental needs, from appointments to inquiries!<\/figcaption><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\">Send Us a Message<\/h2>\n\n\n\n<p>Have any questions or need more information? Fill out the form below, and our team will get back to you promptly. We value your input and look forward to helping you achieve a healthier smile.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Request an Online Consultation<\/h2>\n\n\n\n<p>For your convenience, you can now request an online consultation with our experienced <strong>dentists in Tijuana.<\/strong> Simply provide your details, and we&#8217;ll arrange a virtual meeting to discuss your dental concerns.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Set an Appointment<\/h2>\n\n\n\n<p>Ready to visit us in person? Use our form to set up an appointment with our dental experts. Whether you&#8217;re interested in <a href=\"https:\/\/bestdentistrytijuana.com\/\">Cosmetic or General Dentistry,<\/a> <a href=\"https:\/\/implantsintijuana.com\/\">Dental Implants<\/a>, <a href=\"https:\/\/bracesintijuana.com\/\">Braces<\/a>, <a href=\"https:\/\/rootcanaltooth.com\/\">Root Canal<\/a>, or <a href=\"https:\/\/tijuanadentures.com\/\">Dentures<\/a>, we&#8217;re dedicated to making your experience smooth and pleasant from start to finish.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large is-style-rounded\"><img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"448\" src=\"https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Smile-and-book-your-tijuana-dentist-appointment-today-1-1024x448.jpg\" alt=\"Image of the word &quot;Smile&quot; with each letter featuring a smiling person, promoting dental consultations with a dentist in Tijuana.\" class=\"wp-image-368\" srcset=\"https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Smile-and-book-your-tijuana-dentist-appointment-today-1-1024x448.jpg 1024w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Smile-and-book-your-tijuana-dentist-appointment-today-1-300x131.jpg 300w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Smile-and-book-your-tijuana-dentist-appointment-today-1-768x336.jpg 768w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Smile-and-book-your-tijuana-dentist-appointment-today-1-1536x672.jpg 1536w, https:\/\/beautysmiledentalstudio.com\/dentist-in-tijuana\/wp-content\/uploads\/sites\/2\/2024\/08\/Smile-and-book-your-tijuana-dentist-appointment-today-1.jpg 1600w\" sizes=\"auto, (max-width: 706px) 89vw, (max-width: 767px) 82vw, 740px\" \/><figcaption class=\"wp-element-caption\">Book your appointment today and smile confidently with our top-rated dentist in Tijuana!<\/figcaption><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\">Start Your Insurance Preapproval<\/h2>\n\n\n\n<p>To make your visit as stress-free as possible, start your insurance preapproval process with us. Submit your information, and we&#8217;ll handle the rest, ensuring that your coverage is in place for your dental care.<\/p>\n\n\n\n<h1 class=\"wp-block-heading\">Contact Beauty Smile Dental Studio<\/h1>\n\n\n\n<p>Today and experience the best in dental tourism in Tijuana. We look forward to serving you!<\/p>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f104-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/dentist-in-tijuana\/wp-json\/wp\/v2\/pages\/62#wpcf7-f104-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"104\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.8\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f104-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:104,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;message&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;selection&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Send a Message&quot;}]},{&quot;then_field&quot;:&quot;consultation&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;selection&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Online Consultation&quot;}]},{&quot;then_field&quot;:&quot;appointment&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;selection&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Set an Appointment&quot;}]},{&quot;then_field&quot;:&quot;insurance&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;selection&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Insurance Pre approval&quot;}]},{&quot;then_field&quot;:&quot;ID&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;IDSS&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Insurance ID number&quot;}]},{&quot;then_field&quot;:&quot;SS&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;IDSS&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Social security number&quot;}]},{&quot;then_field&quot;:&quot;yes&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;dependants&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;customer&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;selection&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Satisfaction Survey&quot;}]},{&quot;then_field&quot;:&quot;somewhere&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;somewhere&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Somewhere else&quot;}]},{&quot;then_field&quot;:&quot;Fastlane&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;selection&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Request a Fast Pass&quot;}]},{&quot;then_field&quot;:&quot;somewhere&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;selectionW&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Somewhere else&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false}}\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<p><label> Your Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Your Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n<\/p>\n<p><label> Please Choose an option<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"selection\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"selection\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Send a Message\">Send a Message<\/option><option value=\"Online Consultation\">Online Consultation<\/option><option value=\"Set an Appointment\">Set an Appointment<\/option><option value=\"Insurance Pre approval\">Insurance Pre approval<\/option><option value=\"Request a Fast Pass\">Request a Fast Pass<\/option><option value=\"Satisfaction Survey\">Satisfaction Survey<\/option><\/select><\/span><\/label>\n<\/p>\n<div data-id=\"message\" data-orig_data_id=\"message\"  data-class=\"wpcf7cf_group\">\n\t<p><label> Subject<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-subject\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-subject\" \/><\/span> <\/label>\n\t<\/p>\n\t<p><label> Your Message<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-message\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"your-message\"><\/textarea><\/span> <\/label>\n\t<\/p>\n<\/div>\n<div data-id=\"consultation\" data-orig_data_id=\"consultation\"  data-class=\"wpcf7cf_group\">\n\t<p><label> Subject<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-subject2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-subject2\" \/><\/span> <\/label>\n\t<\/p>\n\t<p><label> Your Consultation<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-consultation\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"your-consultation\"><\/textarea><\/span> <\/label>\n\t<\/p>\n\t<p><label> Upload a Picture or Xray<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Xray\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.pdf,.doc,.png,.jif,.gif,.jpeg,.heic\" aria-invalid=\"false\" type=\"file\" name=\"Xray\" \/><\/span>\n\t<\/p>\n<\/div>\n<div data-id=\"appointment\" data-orig_data_id=\"appointment\"  data-class=\"wpcf7cf_group\">\n\t<p><label> Your Telephone<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"YourTelephoneAP\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"YourTelephoneAP\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label> Visit Purpose<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Purpose\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Purpose\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Check up\">Check up<\/option><option value=\"Dental Cleaning\">Dental Cleaning<\/option><option value=\"Dental Whitening\">Dental Whitening<\/option><option value=\"Toothache\">Toothache<\/option><option value=\"Root Canal\">Root Canal<\/option><option value=\"Dental Implant\">Dental Implant<\/option><option value=\"Crowns and Bridges\">Crowns and Bridges<\/option><option value=\"Dentures\">Dentures<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/label>\n\t<\/p>\n\t<p><label> Select a Date<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label> Select Time<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Time\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Time\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"10:00 am\">10:00 am<\/option><option value=\"11:00 am\">11:00 am<\/option><option value=\"12:00 pm\">12:00 pm<\/option><option value=\"1:00 Pm\">1:00 Pm<\/option><option value=\"3:00 pm\">3:00 pm<\/option><option value=\"4:00 pm\">4:00 pm<\/option><option value=\"5:00 pm\">5:00 pm<\/option><\/select><\/span><\/label>\n\t<\/p>\n<\/div>\n<div data-id=\"insurance\" data-orig_data_id=\"insurance\"  data-class=\"wpcf7cf_group\">\n\t<p><label> Birthdate<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Birthdate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"Birthdate\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label> Your Telephone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"IsuredTel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Area code &amp; Number\" value=\"\" type=\"tel\" name=\"IsuredTel\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label> Address<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Address1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Number &amp; Street\" value=\"\" type=\"text\" name=\"Address1\" \/><\/span><\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Address2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City\" value=\"\" type=\"text\" name=\"Address2\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Address3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"State\" value=\"\" type=\"text\" name=\"Address3\" \/><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Zipcode\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Zip Code\" value=\"\" type=\"text\" name=\"Zipcode\" \/><\/span><br \/>\n<label> Work<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"work\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Company you work for\" value=\"\" type=\"text\" name=\"work\" \/><\/span><\/label><br \/>\n<label> Work Telephone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"WorkTelephone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" placeholder=\"Area Code &amp; Number\" value=\"\" type=\"tel\" name=\"WorkTelephone\" \/><\/span><\/label><br \/>\n<label> Insurance Carrier<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insurance\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your Dental Insurance Company\" value=\"\" type=\"text\" name=\"insurance\" \/><\/span><\/label><br \/>\n<label> Insurance Telephone Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"te\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Area code &amp; Number\" value=\"\" type=\"tel\" name=\"te\" \/><\/span><\/label><br \/>\n<label> Group Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Groupnumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Insurance Group Number\" value=\"\" type=\"text\" name=\"Groupnumber\" \/><\/span><\/label><br \/>\n<label> Please provide one of the next information<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"IDSS\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"IDSS[]\" value=\"Insurance ID number\" \/><span class=\"wpcf7-list-item-label\">Insurance ID number<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"IDSS[]\" value=\"Social security number\" \/><span class=\"wpcf7-list-item-label\">Social security number<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<div data-id=\"ID\" data-orig_data_id=\"ID\"  data-class=\"wpcf7cf_group\">\n\t\t<p><label> Insurance ID number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Idnumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please provide your insurance ID number\" value=\"\" type=\"text\" name=\"Idnumber\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div data-id=\"SS\" data-orig_data_id=\"SS\"  data-class=\"wpcf7cf_group\">\n\t\t<p><label> Social Security Number<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"SSnumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please provide your SS number\" value=\"\" type=\"text\" name=\"SSnumber\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<p><label> Is there any dependent?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dependants\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"dependants[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"dependants[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<div data-id=\"yes\" data-orig_data_id=\"yes\"  data-class=\"wpcf7cf_group\">\n\t\t<p><label> Dependent Name<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dependantname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First and Last Name\" value=\"\" type=\"text\" name=\"dependantname\" \/><\/span><\/label><br \/>\n<label> Dependent's Birthdate<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dependantbirthdate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dependantbirthdate\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div data-id=\"Fastlane\" data-orig_data_id=\"Fastlane\"  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1) Where did you first hear about Beauty Smile Dental Studio? <\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"selectionW\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"selectionW\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"A friend or Family\">A friend or Family<\/option><option value=\"Social Media\">Social Media<\/option><option value=\"Google \/ online search\">Google \/ online search<\/option><option value=\"Somewhere else\">Somewhere else<\/option><\/select><\/span>\n\t<\/p>\n\t<div data-id=\"somewhere\" data-orig_data_id=\"somewhere\"  data-class=\"wpcf7cf_group\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"somewhere\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Please specify\" value=\"\" 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