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130<div class="menu-hide" id="gpw-main-menu"> 131<ul class="nav navbar-nav" > 132<li class="home"> 133<a href="/" title="Home" >Home</a> 134</li> 135<li class="dropdown about"> 136<a href="/about-us" class="dropdown-toggle" data-toggle="dropdown" role="button" aria-expanded="false" > 137About 138<span class="caret"></span> 139</a> 140<ul class="dropdown-menu dropdown-click list-unstyled"> 141<li><a class="nav-link" href="/about-us">Our Team</a></li> 142<li> 143<a href="/technology" class="nav-link" >Amenities & Technology</a> 144</li> 145</ul> 146</li> 147<li class="dropdown yamm-fw services"> 148<a href="/services" title="..." >General</a> 149<ul class="dropdown-menu"> 150<div class="yamm-content"> 151<div class="row"> 152<ul class="col-md-12 list-unstyled"> 153<li class="visible-xs"> 154<a href="/services" title="View All..." class="nav-link" >View All</a> 155</li> 156<li><a href="/services/general-dentistry/35777" title="General Dentistry..." class="nav-link" data-id="35777">General 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href="/services/childrens-dentistry/35780" title="Childrens Dentistry"> 174Kids 175</a> 176</li> 177<li class="services-36382 dropdown yamm-fw" > 178<a href="/services/implants/36382" title="Implants"> 179Implants 180</a> 181<ul class="dropdown-menu"> 182<div class="yamm-content"> 183<div class="row"> 184<ul class="col-md-12 list-unstyled"> 185<li class="visible-xs"> 186<a href="/services/implants/36382" title="Implants" class="nav-link"> 187View All 188</a> 189</li> 190<li> 191<a href="/services/dental-implants/35782" title="Dental Implants..." class="nav-link" data-id="35782">Dental Implants</a> 192</li> 193<li> 194<a href="/services/allon4/35783" title="All-On-4..." class="nav-link" data-id="35783">All-On-4</a> 195</li> 196</ul> 197</div> 198</div> 199</ul> 200</li> 201<li class="services-36381 yamm-fw" > 202<a href="/services/orthodontics/36381" title="Orthodontics"> 203Orthodontics 204</a> 205</li> 206<li class="services-36383 dropdown yamm-fw" > 207<a href="/services/cosmetic/36383" title="Cosmetic"> 208Cosmetic 209</a> 210<ul class="dropdown-menu"> 211<div class="yamm-content"> 212<div class="row"> 213<ul class="col-md-12 list-unstyled"> 214<li class="visible-xs"> 215<a href="/services/cosmetic/36383" title="Cosmetic" class="nav-link"> 216View All 217</a> 218</li> 219<li> 220<a href="/services/teeth-whitening/36416" title="Teeth Whitening..." class="nav-link" data-id="36416">Teeth Whitening</a> 221</li> 222<li> 223<a href="/services/smile-rejuvenation/35789" title="Smile Rejuvenation..." class="nav-link" data-id="35789">Smile Rejuvenation</a> 224</li> 225<li> 226<a href="/services/restorative-dentistry/35781" title="Restorative Dentistry..." class="nav-link" data-id="35781">Restorative Dentistry</a> 227</li> 228<li> 229<a href="/services/dentures/35788" title="Dentures..." class="nav-link" data-id="35788">Dentures</a> 230</li> 231<li> 232<a href="/services/dental-veneers/35790" title="Dental Veneers..." class="nav-link" data-id="35790">Dental Veneers</a> 233</li> 234<li> 235<a href="/services/cosmetic-dentistry/35784" title="Cosmetic Dentistry..." class="nav-link" data-id="35784">Cosmetic Dentistry</a> 236</li> 237</ul> 238</div> 239</div> 240</ul> 241</li> 242<li class="dropdown yamm-fw gallery"> 243<a href="/smile-gallery" >Gallery</a> 244</li> 245<li class="dropdown patient-info"> 246<a href="/patient-information" class="dropdown-toggle" data-toggle="dropdown" role="button" aria-expanded="false"> 247Patient Info 248<span class="caret"></span> 249</a> 250<ul id="patient-dropdown" class="dropdown-menu"> 251<div class="yamm-content"> 252<div class="row"> 253<ul class="col-md-12 list-unstyled"> 254<li class="visible-xs"> 255<a href="/patient-information" title="View Patient Info" class="nav-link" >View Patient Info</a> 256</li> 257<li><a href="/first-visit" title="Your First Visit" class="nav-link" >Your First Visit</a></li> 258<li><a href="/forms" class="nav-link" >Forms</a></li> 259<li><a 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303<a target="_blank" href="https://www.centaurportal.com/d4w/org-2920/search?sourceID=null"></a> 304</div> 305</div> 306</div> 307</header> 308</div> 309</div> 310<div class="section-wrap" id="breadcrumbs-wrap"> 311<div class="container"> 312<div class="bread-wrap"> 313<div id="bread-crumbs" class="row"> 314<div class="col-sm-12"> 315<a href="https://www.baysidesmiles.com.au">Bayside Smiles</a> > <a href="https://www.baysidesmiles.com.au/contact">Contact Us Bayside Smiles - Black Rock</a> 316</div> 317</div> 318</div> 319</div> 320</div> 321<div class="section-wrap" id="banner-wrap"> 322<div class="container"> 323<div id="banner-snip" class="row hidden-xs"> 324<div class="col-sm-12"> 325<div id="homepage-banner" class="banner"> 326<div class="bannerText"> 327<div class="bannerHeader"></div> 328<div class="bannerSubheader"></div> 329<div class="bannerTeaser"></div> 330<div class="bannerButtonText"></div> 331</div> 332</div> 333</div> 334</div> 335</div> 336</div> 337<main class="section-wrap" id="main-wrap" role="main" tabindex="-1"> 338<div class="gpw-location-banner module-center theme-bg-light"> 339<img class="gpw-banner-img img-responsive" 340src="/thedentalsitecontent/1003953/location/bayside-smiles.jpeg" 341alt=""> 342<div class="gpw-banner-text-cont"> 343<div class="container"> 344<h1 class="page-title theme-color-dk wow fadeInDown"> 345Contact Us Bayside Smiles - Black Rock 346</h1> 347</div> 348</div> 349</div> 350<div class="gpw-location-info module-background-white module-wrap"> 351<div class="container"> 352<div class="col-sm-6 col-md-7"> 353<h2 class="visible-xs"> 354Contact This Location 355</h2> 356<style type="text/css"> 357.recaptcha-statement { 358font-size: 12px; 359margin-top: 15px; 360margin-bottom: 10px; 361} 362.grecaptcha-badge { 363visibility: hidden; 364} 365#contactform fieldset.patient-type-group { 366border: 0; 367padding: 0; 368margin: 0; 369min-width: 0; 370} 371#contactform fieldset.patient-type-group legend.label-style { 372border: 0; 373margin-bottom: 0; 374font-size: inherit; 375line-height: inherit; 376display: inline; 377float: none; 378width: auto; 379padding: 0; 380margin-right: 0.25em; 381} 382#contactform .day-of-week .checkbox label { 383font-weight: normal; 384margin-bottom: 0; 385} 386</style> 387<div class="contact-form"> 388<div style="display: none;" id="customFormWrap" aria-hidden="true"> 389<iframe id="customForm" src="" width="100%" 390height="550" style="border:none;" title="Location Contact Form"></iframe> 391</div> 392<form style="display: none;" role="form" action="/email/sendContactForm" 393autocomplete="off" id="contactform" 394method="post" name="contactform" class="form-horizontal"> 395<input type="hidden" id="utm_campaign" name="utm_campaign" value=""> 396<input type="hidden" id="utm_content" name="utm_content" value=""> 397<input type="hidden" id="utm_source" name="utm_source" value=""> 398<input type="hidden" id="utm_term" name="utm_term" value=""> 399<input type="hidden" id="utm_medium" name="utm_medium" value=""> 400<input type="hidden" id="currentEvent" name="currentEvent" value="contact.default"> 401<input type="hidden" id="currentURL" name="currentURL"> 402<input type="hidden" name="locationID" id="locationID" value="4176"> 403<input type="hidden" name="pageTitle" id="pageTitle" value="Contact Us Bayside Smiles - Black Rock"> 404<input type="hidden" name="contactForm" value='contactpage'> 405<div class="form-group"> 406<div class="col-xs-12"> 407<label for="appt_radio" class="radio-inline"> 408<input class="conradio" type="radio" name="contacttype" value="appt" id="appt_radio" checked="checked" /> 409<span> 410Book Now 411</span> 412</label> 413<label for="contact_radio" class="radio-inline"> 414<input class="conradio" type="radio" name="contacttype" value="contact" id="contact_radio" /> 415<span>Contact Us</span> 416</label> 417</div> 418</div> 419<div class="col-xs-12"> 420<div class="gpw-3rd-Party theme-border-cta"> 421<div class="contact-form-headline">Ready to Schedule an Appointment?</div> 422<a class="appt-btn cta-btn gpw-banner-cta-btn theme-cta-bg theme-cta-color theme-border-cta theme-hover-cta-color theme-hover-cta-bg theme-hover-border-cta" href="https://healthengine.com.au/book/35000" target="_blank"> 423Book Now 424</a> 425</div> 426</div> 427<div class="contact-form-headline">Have Questions? 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495<option value="New Patient Cleaning/Exam">New Patient Cleaning/Exam</option> 496<option value="New Patient Consultation">New Patient Consultation</option> 497<option value="Existing Patient Continuing Care">Existing Patient Continuing Care</option> 498<option value="Dental Representative Meeting Request">Dental Representative Meeting Request</option> 499<option value="Other">Other</option> 500</select> 501</div> 502</div> 503<div class="form-group"> 504<div class="col-xs-12"> 505<span class="label-style">Appointment Preferences</span> 506</div> 507<div class="col-xs-12"> 508<div id="days-location_4176" class="location-days checkbox-wrap"> 509<div class="day-of-week"> 510<div class="checkbox"> 511<input type="checkbox" value="Monday" class="checkbox" name="appointmentday" id="mon" /> 512<label for="mon">Monday</label> 513</div> 514</div> 515<div class="day-of-week"> 516<div class="checkbox"> 517<input type="checkbox" value="Tuesday" class="checkbox" name="appointmentday" id="tue" /> 518<label for="tue">Tuesday</label> 519</div> 520</div> 521<div class="day-of-week"> 522<div class="checkbox"> 523<input type="checkbox" value="Wednesday" class="checkbox" name="appointmentday" id="wed" /> 524<label for="wed">Wednesday</label> 525</div> 526</div> 527<div class="day-of-week"> 528<div class="checkbox"> 529<input type="checkbox" value="Thursday" class="checkbox" name="appointmentday" id="thu" /> 530<label for="thu">Thursday</label> 531</div> 532</div> 533<div class="day-of-week"> 534<div class="checkbox"> 535<input type="checkbox" value="Friday" class="checkbox" name="appointmentday" id="fri" /> 536<label for="fri">Friday</label> 537</div> 538</div> 539</div> 540</div> 541</div> 542</div> 543<div class="form-group"> 544<div class="col-sm-12 "> 545<label for="message">Additional Comments</label> 546<textarea placeholder="How can we help you?" cols="40" rows="4" class="form-control text-input textField" id="message" name="message"> 547</textarea> 548</div> 549</div> 550<div class="form-group"> 551<div class="col-xs-12 contact-notes"> 552</div> 553</div> 554<div class="form-group"> 555<div class="recaptcha-statement"> 556This site is protected by reCAPTCHA and the Google <a href="https://policies.google.com/privacy" target="_blank">Privacy Policy</a> and <a href="https://policies.google.com/terms" target="_blank">Terms of Service</a> apply. 557</div> 558<div class="required-hint">Required Field</div> 559<div id="contact-form-errors" role="alert" aria-live="polite" aria-atomic="true"></div> 560<div class="col-xs-12 submit-area"> 561<input class="cta-btn gpw-banner-cta-btn theme-cta-bg theme-cta-color theme-border-cta theme-hover-cta-color theme-hover-cta-bg theme-hover-border-cta btn btn-default submit-contact g-recaptcha" type="button" id="submitter" name="submitter" value="Submit" data-sitekey="6LfLLO4aAAAAAGGfIiRkFVZ-wthfWmeOm5uzpNMF" data-callback="checkReCAPTCHAResponse" data-action="contactForm" /> 562<button type="button" class="cta-btn gpw-banner-cta-btn theme-cta-bg theme-cta-color theme-border-cta theme-hover-cta-color theme-hover-cta-bg theme-hover-border-cta btn btn-default submit-contact" disabled style="display: none;background: #54575C;margin-bottom: 10px" id="submitterDisabled">Sending...</button> 563</div> 564</div> 565</form> 566</div>
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571<script type="text/javascript"> 572window.gpwContactForm = {"locationCount":1,"useSpamControl":true,"bookingLink":"https://healthengine.com.au/book/35000","locationVendors":[{"uri":"https://www.centaurportal.com/d4w/org-2920/search?sourceID=nulla","anchorContent":"href=\"https://www.centaurportal.com/d4w/org-2920/search?sourceID=nulla\" target=\"_blank\"","locationID":4176}],"doctors":[{"location":"4176","doctor":"Dr Michael Letham, BDS (Hons)"},{"location":"4176","doctor":"Dr Henry Yang, BDS (Hons)"},{"location":"4176","doctor":"Dr Mihir Hargovan, BDS (Hons), MClinDent (UK)"},{"location":"4176","doctor":"Dr Becky Liefting"},{"location":"4176","doctor":"Dr Nayna Mistry, BChD"},{"location":"4176","doctor":"Nicole Brodie"}],"podiumLocation":""}; 573</script>
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574 575</div> <!-- /.col-sm-6 col-md-7 --> 576<div class="row location-details"> 577<div class="col-sm-6 col-md-5"> 578<div class="location-information"> 579<div class="infoWrap"> 580<b>Phone:</b> 581<div class="infoContentWrap"> 582<a href="tel:0395982100" onclick="gdw.recordCall(0395982100);"> 583<span class="theme-hover-cta-color">(03) 9598 2100</span> 584</a> 585</div> 586</div> 587<div class="infoWrap"> 588<b>Address:</b> 589<div class="infoContentWrap"> 590<a target="_blank" href="https://maps.google.com/maps?f=q&source=s_q&hl=en&geocode=&q=104+Bluff+Road+Black+Rock+VIC+3193"> 591<span class="theme-hover-cta-color">104 Bluff Road<br/></span> 592<span class="theme-hover-cta-color">Black Rock</span> 593, 594<span class="theme-hover-cta-color">VIC</span> 595<span class="theme-hover-cta-color"> 3193</span> 596</a> 597</div> 598</div> 599<div class="locationHours infoWrap"> 600<strong>Hours:</strong><br /> 601<div class="Mon-wrap single-day-hours"> 602<div class="day-open"> 603Monday 604</div> 605<div class="hours-open"> 606<time datetime="Mo 08:00 - 18:00"> 6078:00AM - 6:00PM 608</time> 609<span class="delim"> | </span> 610</div> 611</div> 612<div class="Tue-wrap single-day-hours"> 613<div class="day-open"> 614Tuesday 615</div> 616<div class="hours-open"> 617<time datetime="Tu 08:00 - 18:00"> 6188:00AM - 6:00PM 619</time> 620<span class="delim"> | </span> 621</div> 622</div> 623<div class="Wed-wrap single-day-hours"> 624<div class="day-open"> 625Wednesday 626</div> 627<div class="hours-open"> 628<time datetime="We 09:00 - 18:00"> 6299:00AM - 6:00PM 630</time> 631<span class="delim"> | </span> 632</div> 633</div> 634<div class="Thu-wrap single-day-hours"> 635<div class="day-open"> 636Thursday 637</div> 638<div class="hours-open"> 639<time datetime="Th 08:00 - 18:00"> 6408:00AM - 6:00PM 641</time> 642<span class="delim"> | </span> 643</div> 644</div> 645<div class="Fri-wrap single-day-hours"> 646<div class="day-open"> 647Friday 648</div> 649<div class="hours-open"> 650<time datetime="Fr 08:00 - 13:00"> 6518:00AM - 1:00PM 652</time> 653<span class="delim"> | </span> 654</div> 655</div> 656<div class="Sat-wrap single-day-hours"> 657<div class="day-open"> 658Saturday 659</div> 660<div class="hours-open"> 661<em>Closed</em> 662</div> 663</div> 664<div class="Sun-wrap single-day-hours"> 665<div class="day-open"> 666Sunday 667</div> 668<div class="hours-open"> 669<em>Closed</em> 670</div> 671</div> 672</div> 673</div> <!-- /.location-information --> 674</div> 675</div> <!-- /.row.location-details --> 676</div> <!-- /.container --> 677</div> <!-- /.gpw-location-info --> 678<div class="gpw-loc-pagecontent module-background-white"> 679<div class="gpw-loc-decorative-border gpw-left-border theme-bg-med"></div> 680<div class="gpw-loc-decorative-border gpw-right-border theme-bg-dk"></div> 681<div class="container no-pad-bottom"> 682<div id="main" class="version2"> 683<div class="infoPractice module-header-1"> 684Practice Information 685</div> 686<p>Bayside Smiles was established in 2006 by a local family for local families. Since our humble beginnings, we have grown into a dedicated team of dentists and team members, caring for our communities in Black Rock (since 2006).</p> 687<p> </p> 688<h5>Goals for Our Dental Practice</h5> 689<p>Our vision is to be the community's most loved and respected dental practice. We aim to do this by providing the most caring dentistry imaginable, tailored to each patient's needs, focusing on modern techniques, longevity and optimal health.</p> 690<p>We look forward to caring for you and will do everything we can to address your needs – big or small.</p> 691</div> 692</div> 693</div> 694<div id="gpw-map-and-staff"> 695<div class="container-fluid"> 696<div class="row bootstrap-flex-row"> 697<div id="map" class="col-sm-6 bootstrap-flex-col"></div> 698<div class="col-sm-6 bootstrap-flex-col theme-bg-light"> 699<div id="gpw-staff-slider" class="flexslider init-slider" data-direction="false" data-animation="fade"> 700<div class="module-header-1">Featured Staff</div> 701<ul class="slides"> 702<li class="slide slide1"> 703<img src="/thedentalsitecontent/1003953/dentists/dr-michael-letham-2.jpg" class="img-responsive" alt=""> 704<div class="gpw-staff-name"> 705Dr Michael Letham, BDS (Hons) 706</div> 707<div class="gpw-staff-link"> 708<a href="/about-us"> 709See Complete Bio 710</a> 711</div> 712</li> 713<li class="slide slide2"> 714<img src="/thedentalsitecontent/1003953/dentists/dr-henry-yang.jpg" class="img-responsive" alt=""> 715<div class="gpw-staff-name"> 716Dr Henry Yang, BDS (Hons) 717</div> 718<div class="gpw-staff-link"> 719<a href="/about-us"> 720See Complete Bio 721</a> 722</div> 723</li> 724<li class="slide slide3"> 725<img src="/thedentalsitecontent/1003953/dentists/dr-mihir-hargovan.jpg" class="img-responsive" alt=""> 726<div class="gpw-staff-name"> 727Dr Mihir Hargovan, BDS (Hons), MClinDent (UK) 728</div> 729<div class="gpw-staff-link"> 730<a href="/about-us"> 731See Complete Bio 732</a> 733</div> 734</li> 735<li class="slide slide4"> 736<img src="/thedentalsitecontent/1003953/dentists/dr-becky-liefting-dentist.jpg" class="img-responsive" alt=""> 737<div class="gpw-staff-name"> 738Dr Becky Liefting 739</div> 740<div class="gpw-staff-link"> 741<a href="/about-us"> 742See Complete Bio 743</a> 744</div> 745</li> 746<li class="slide slide5"> 747<img src="/thedentalsitecontent/1003953/dentists/dr-nayna-mistry-dentist-moorabbin.jpg" class="img-responsive" alt="Dr Mistry is a dentist moorabbin"> 748<div class="gpw-staff-name"> 749Dr Nayna Mistry, BChD 750</div> 751<div class="gpw-staff-link"> 752<a href="/about-us"> 753See Complete Bio 754</a> 755</div> 756</li> 757<li class="slide slide6"> 758<img src="/thedentalsitecontent/1003953/dentists/nicole--brodie-hygienist.png" class="img-responsive" alt="Nicole Brodie Hygienist"> 759<div class="gpw-staff-name"> 760Nicole Brodie 761</div> 762<div class="gpw-staff-link"> 763<a href="/about-us"> 764See Complete Bio 765</a> 766</div> 767</li> 768</ul> 769</div> 770</div> 771</div> 772</div> 773</div> 774<div id="gpw-services-output" class="module-background-white"> 775<div class="container"> 776<div class="row bootstrap-flex-row"> 777<div class="col-sm-12 gpw-services-headline module-header-1"> 778<div class="headline-wrap theme-color-med theme-border-cta"> 779<a 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1205Send Us an Email</div> 1206<style type="text/css"> 1207.recaptcha-statement { 1208font-size: 12px; 1209margin-top: 15px; 1210margin-bottom: 10px; 1211} 1212.grecaptcha-badge { 1213visibility: hidden; 1214} 1215#modal-contactform fieldset.patient-type-group { 1216border: 0; 1217padding: 0; 1218margin: 0; 1219min-width: 0; 1220} 1221#modal-contactform fieldset.patient-type-group legend.label-style { 1222border: 0; 1223margin-bottom: 0; 1224font-size: inherit; 1225line-height: inherit; 1226display: inline; 1227float: none; 1228width: auto; 1229padding: 0; 1230margin-right: 0.25em; 1231} 1232#modal-contactform .day-of-week .checkbox label { 1233font-weight: normal; 1234margin-bottom: 0; 1235} 1236</style> 1237<div class="contact-form"> 1238<div style="display: none;" id="modal-customFormWrap" aria-hidden="true"> 1239<iframe id="modal-customForm" src="" width="100%" 1240height="550" style="border:none;" title="Location Contact Form"></iframe> 1241</div> 1242<form style="display: none;" role="form" action="/email/sendContactForm" 1243autocomplete="off" id="modal-contactform" 1244method="post" name="contactform" class="form-horizontal"> 1245<input type="hidden" id="modal-utm_campaign" name="utm_campaign" value=""> 1246<input type="hidden" id="modal-utm_content" name="utm_content" value=""> 1247<input type="hidden" id="modal-utm_source" name="utm_source" value=""> 1248<input type="hidden" id="modal-utm_term" name="utm_term" value=""> 1249<input type="hidden" id="modal-utm_medium" name="utm_medium" value=""> 1250<input type="hidden" id="modal-currentEvent" name="currentEvent" value="contact.default"> 1251<input type="hidden" id="modal-currentURL" name="currentURL"> 1252<input type="hidden" name="locationID" id="modal-locationID" value="4176"> 1253<input type="hidden" name="pageTitle" id="modal-pageTitle" value="Contact Us Bayside Smiles - Black Rock"> 1254<input type="hidden" name="contactForm" value='contactpage'> 1255<div class="form-group"> 1256<div class="col-xs-12"> 1257<label for="modal-appt_radio" class="radio-inline"> 1258<input class="conradio" type="radio" name="contacttype" value="appt" id="modal-appt_radio" checked="checked" /> 1259<span> 1260Book Now 1261</span> 1262</label> 1263<label for="modal-contact_radio" class="radio-inline"> 1264<input class="conradio" type="radio" name="contacttype" value="contact" id="modal-contact_radio" /> 1265<span>Contact Us</span> 1266</label> 1267</div> 1268</div> 1269<div class="col-xs-12"> 1270<div class="gpw-3rd-Party theme-border-cta"> 1271<div class="contact-form-headline">Ready to Schedule an Appointment?</div> 1272<a class="appt-btn cta-btn gpw-banner-cta-btn theme-cta-bg theme-cta-color theme-border-cta theme-hover-cta-color theme-hover-cta-bg theme-hover-border-cta" href="https://healthengine.com.au/book/35000" target="_blank"> 1273Book Now 1274</a> 1275</div> 1276</div> 1277<div class="contact-form-headline">Have Questions? Contact Us:</div> 1278<hr> 1279<div class="form-group"> 1280<div class="col-sm-12"> 1281<label for="modal-fullname" class="required">Full Name <span class="req-indicator">* (Req)</span></label> 1282<input placeholder="Your Name (First and Last)" class="form-control required textField" type="text" maxlength="100" name="fullname" id="modal-fullname"/> 1283</div> 1284<input class="form-control" style="display:none" type="text" name="middlename" id="modal-middlename" value="" /> 1285<div class="phone-group col-sm-12 col-md-6" style="padding-top: 10px;"> 1286<label for="modal-phone">Phone</label> 1287<input placeholder="Phone" class="form-control text-input textField mar-top-5" type="text" maxlength="100" name="phone" id="modal-phone"/> 1288</div> 1289<div class="email-group col-sm-12 col-md-6" style="padding-top: 10px;"> 1290<label for="modal-email" class="required">Email <span class="req-indicator">* (Req)</span></label> 1291<input placeholder="Email" class="form-control required email text-input textField mar-top-5" type="email" maxlength="100" name="email" id="modal-email"/> 1292</div> 1293</div> 1294<div class="form-group"> 1295<div class="col-sm-12"> 1296<fieldset class="patient-type-group" role="radiogroup"> 1297<legend class="label-style">Are you a?</legend> 1298<span class="patient-radios" style="display: inline-block"> 1299<label for="modal-newPatient" class="patient-radio radio-inline"> 1300<input class="conradio" type="radio" name="newOrExisting" id="modal-newPatient" value="New Patient" > 1301<span>New Patient </span> 1302</label> 1303<label for="modal-existingPatient" class="patient-radio radio-inline"> 1304<input class="conradio" type="radio" name="newOrExisting" id="modal-existingPatient" value="Current Patient" > 1305<span>Current Patient</span> 1306</label> 1307</span> 1308</fieldset> 1309</div> 1310</div> 1311<div class="col-sm-12 col-md-6 select"> 1312<label for="modal-howToContact"> 1313How would you like us to contact you? 1314</label> 1315<select name="howToContact" id="modal-howToContact" class="how-contact"> 1316<option value="">Please choose</option> 1317<option value="Email">Email</option> 1318<option value="Call">Call</option> 1319</select> 1320</div> 1321<div class="col-sm-12 col-md-6 select-right"> 1322<label for="modal-howHeardAbout"> 1323How did you hear about us? 1324</label> 1325<select name="howHeardAbout" id="modal-howHeardAbout" class="how-heard" onchange="referralSelect()"> 1326<option value="">Please choose</option> 1327<option value="I'm an existing patient">I'm an existing patient</option> 1328<option value="Google/Bing">Google/Bing</option> 1329<option value="Mailer">Mailer</option> 1330<option value="Word of mouth">Word of mouth</option> 1331<option value="Social media">Social media</option> 1332<option value="Other">Other</option> 1333</select> 1334<label class="sr-only" for="modal-referral">Who Referred You?:</label> 1335<input placeholder="Who referred you?" class="text-input textField who-referred mar-top-5" style="display: none;" type="text" maxlength="100" name="referral" id="modal-referral"/> 1336</div> 1337<div id="modal-appointment"> 1338<div class="form-group"> 1339<div class="col-xs-12"> 1340<label for="modal-appointmentType">Appointment Type?</label> 1341</div> 1342<div class="col-xs-12"> 1343<select name="appointmentType" id="modal-appointmentType" class="appt-type"> 1344<option value="">Please choose</option>
1345<option value="New Patient Cleaning/Exam">New Patient Cleaning/Exam</option> 1346<option value="New Patient Consultation">New Patient Consultation</option> 1347<option value="Existing Patient Continuing Care">Existing Patient Continuing Care</option> 1348<option value="Dental Representative Meeting Request">Dental Representative Meeting Request</option> 1349<option value="Other">Other</option> 1350</select> 1351</div> 1352</div> 1353<div class="form-group"> 1354<div class="col-xs-12"> 1355<span class="label-style">Appointment Preferences</span> 1356</div> 1357<div class="col-xs-12"> 1358<div id="modal-days-location_4176" class="location-days checkbox-wrap"> 1359<div class="day-of-week"> 1360<div class="checkbox"> 1361<input type="checkbox" value="Monday" class="checkbox" name="appointmentday" id="modal-mon" /> 1362<label for="modal-mon">Monday</label> 1363</div> 1364</div> 1365<div class="day-of-week"> 1366<div class="checkbox"> 1367<input type="checkbox" value="Tuesday" class="checkbox" name="appointmentday" id="modal-tue" /> 1368<label for="modal-tue">Tuesday</label> 1369</div> 1370</div> 1371<div class="day-of-week"> 1372<div class="checkbox"> 1373<input type="checkbox" value="Wednesday" class="checkbox" name="appointmentday" id="modal-wed" /> 1374<label for="modal-wed">Wednesday</label> 1375</div> 1376</div> 1377<div class="day-of-week"> 1378<div class="checkbox"> 1379<input type="checkbox" value="Thursday" class="checkbox" name="appointmentday" id="modal-thu" /> 1380<label for="modal-thu">Thursday</label> 1381</div> 1382</div> 1383<div class="day-of-week"> 1384<div class="checkbox"> 1385<input type="checkbox" value="Friday" class="checkbox" name="appointmentday" id="modal-fri" /> 1386<label for="modal-fri">Friday</label> 1387</div> 1388</div> 1389</div> 1390</div> 1391</div> 1392</div> 1393<div class="form-group"> 1394<div class="col-sm-12 "> 1395<label for="modal-message">Additional Comments</label> 1396<textarea placeholder="How can we help you?" cols="40" rows="4" class="form-control text-input textField" id="modal-message" name="message"> 1397</textarea> 1398</div> 1399</div> 1400<div class="form-group"> 1401<div class="col-xs-12 contact-notes"> 1402</div> 1403</div> 1404<div class="form-group"> 1405<div class="recaptcha-statement"> 1406This site is protected by reCAPTCHA and the Google <a href="https://policies.google.com/privacy" target="_blank">Privacy Policy</a> and <a href="https://policies.google.com/terms" target="_blank">Terms of Service</a> apply. 1407</div> 1408<div class="required-hint">Required Field</div> 1409<div id="modal-contact-form-errors" role="alert" aria-live="polite" aria-atomic="true"></div> 1410<div class="col-xs-12 submit-area"> 1411<input class="cta-btn gpw-banner-cta-btn theme-cta-bg theme-cta-color theme-border-cta theme-hover-cta-color theme-hover-cta-bg theme-hover-border-cta btn btn-default submit-contact g-recaptcha" type="button" id="modal-submitter" name="submitter" value="Submit" data-sitekey="6LfLLO4aAAAAAGGfIiRkFVZ-wthfWmeOm5uzpNMF" data-callback="checkReCAPTCHAResponsemodal" data-action="contactForm" /> 1412<button type="button" class="cta-btn gpw-banner-cta-btn theme-cta-bg theme-cta-color theme-border-cta theme-hover-cta-color theme-hover-cta-bg theme-hover-border-cta btn btn-default submit-contact" disabled style="display: none;background: #54575C;margin-bottom: 10px" id="modal-submitterDisabled">Sending...</button> 1413</div> 1414</div> 1415</form> 1416</div>
vendor: 65 bytes, lines 1416-1417
1416 1417<script src='https://www.google.com/recaptcha/api.js'></script>
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1418 1419</div> 1420</div> 1421</div> 1422</div> 1423</div> 1424</div> 1425<div id="gallery-testimonial-modal" class="modal fade" tabindex="-1" role="dialog" aria-labelledby="gallery-testimonial-modal"> 1426<div class="modal-dialog"> 1427<div class="modal-content"> 1428<div class="modal-header pod"> 1429<button type= "button" class="close" data-dismiss="modal" aria-label="Close"><span aria-hidden="true">×</span></button> 1430<div class="modal-title">This Patient's Experience</div> 1431</div> 1432<div class="modal-body"> 1433<div id="gpw-loading-testimonial" style="display: none;"> 1434<span class="fa-stack fa-3x"> 1435<i class="fa fa-comment-o fa-stack-2x theme-color-dk" aria-hidden="true"></i> 1436<i class="fa fa-spinner fa-stack-1x fa-spin theme-color-med" aria-hidden="true"></i> 1437</span> 1438<div class="theme-color-dk">Loading Testimonial...</div> 1439</div> 1440<div id="gpw-loading-gallery" style="display: none;"> 1441<i class="fa gallery fa-spinner fa-spin fa-4x theme-color-med" aria-hidden="true"></i> 1442<div class="theme-color-dk">Loading Case...</div> 1443</div> 1444<div id="gallery-testimonial-modal-content"></div> 1445</div> 1446</div> 1447</div> 1448</div>
1449<script src="/js/gpw-public.min.js" type="text/javascript"></script>
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1449
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