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HTML Settings

Here you can Sed posuere consectetur est at lobortis. Donec ullamcorper nulla non metus auctor fringilla. Maecenas sed diam eget risus varius blandit sit amet non magna. Donec id elit non mi porta gravida at eget metus. Praesent commodo cursus magna, vel scelerisque nisl consectetur et.

            
              <form class="jotform-form" action="#" method="post"
		  name="form_1234" id="1234" accept-charset="utf-8"><input type="hidden" name="formID"
																					   value="1234"/>
		<div class="form-all">
			<ul class="form-section page-section">

				<li class="form-line" data-type="control_text" id="id_21">
					<div id="cid_21" class="form-input-wide">
						<div id="text_21" class="form-html"><p><span
									style="font-size:14pt;"><strong>Hi! </strong></span></p>
							<p><span style="font-size:14pt;">Before we book an appointment, please give us some information so that we can check your benefits before you arrive.</span>
							</p>
							<p style="text-align:center;"><span style="font-size:10pt;"><em>(by the way, this information is transferred securely to our servers.)</em></span>
							</p></div>
					</div>
				</li>
				<li id="cid_24" class="form-input-wide" data-type="control_pagebreak">
					<div class="form-pagebreak">
						<div class="form-pagebreak-back-container">
							<button type="button" class="form-pagebreak-back " id="form-pagebreak-back_24"> Back
							</button>
						</div>
						<div class="form-pagebreak-next-container">
							<button type="button" class="form-pagebreak-next " id="form-pagebreak-next_24"> Next
							</button>
						</div>
            </div>
				</li>
			</ul>
			<ul class="form-section page-section" style="display:none;">
				<li class="form-line" data-type="control_text" id="id_27">
					<div id="cid_27" class="form-input-wide">
						<div id="text_27" class="form-html"><p><span style="font-size:14pt;">Please fill out the following:<br/></span>
							</p></div>
					</div>
				</li>
				<li class="form-line jf-required" data-type="control_fullname" id="id_3"><label
						class="form-label form-label-left form-label-auto" id="label_3" for="input_3"> Name: <span
							class="form-required"> * </span> </label>
					<div id="cid_3" class="form-input jf-required"><span class="form-sub-label-container"
																		 style="vertical-align: top"> <input
								class="form-textbox validate[required]" type="text" size="10" name="q3_name[first]"
								id="first_3"/> <label class="form-sub-label" for="first_3" id="sublabel_first"
													  style="min-height: 13px;"> First Name </label> </span> <span
							class="form-sub-label-container" style="vertical-align: top"> <input
								class="form-textbox validate[required]" type="text" size="15" name="q3_name[last]"
								id="last_3"/> <label class="form-sub-label" for="last_3" id="sublabel_last"
													 style="min-height: 13px;"> Last Name </label> </span></div>
				</li>
				<li class="form-line jf-required" data-type="control_phone" id="id_29"><label
						class="form-label form-label-left form-label-auto" id="label_29" for="input_29"> Phone Number
						<span class="form-required"> * </span> </label>
					<div id="cid_29" class="form-input jf-required"><span class="form-sub-label-container"
																		  style="vertical-align: top"> <input
								class="form-textbox validate[required]" type="tel" name="q29_phoneNumber[area]"
								id="input_29_area" size="3"> <span class="phone-separate"> &nbsp;- </span> <label
								class="form-sub-label" for="input_29_area" id="sublabel_area" style="min-height: 13px;"> Area Code </label> </span>
						<span class="form-sub-label-container" style="vertical-align: top"> <input
								class="form-textbox validate[required]" type="tel" name="q29_phoneNumber[phone]"
								id="input_29_phone" size="8"> <label class="form-sub-label" for="input_29_phone"
																	 id="sublabel_phone" style="min-height: 13px;"> Phone Number </label> </span>
					</div>
				</li>
				<li class="form-line" data-type="control_email" id="id_4"><label
						class="form-label form-label-left form-label-auto" id="label_4" for="input_4"> E-mail: </label>
					<div id="cid_4" class="form-input jf-required"><input type="email"
																		  class=" form-textbox validate[Email]"
																		  id="input_4" name="q4_email" size="30"
																		  value=""/></div>
				</li>
				<li id="cid_26" class="form-input-wide" data-type="control_pagebreak">
					<div class="form-pagebreak">
						<div class="form-pagebreak-back-container">
							<button type="button" class="form-pagebreak-back " id="form-pagebreak-back_26"> Back
							</button>
						</div>
						<div class="form-pagebreak-next-container">
							<button type="button" class="form-pagebreak-next " id="form-pagebreak-next_26"> Next
							</button>
						</div>
					</div>
				</li>
			</ul>
			<ul class="form-section page-section" style="display:none;">
				<li class="form-line" data-type="control_text" id="id_28">
					<div id="cid_28" class="form-input-wide">
						<div id="text_28" class="form-html"><p style="text-align:left;"><span style="font-size:10pt;">If you would like us to file with your insurance provider, please fill out the following information so that we can verify your benefits before your arrival.</span>
							</p></div>
					</div>
				</li>
        <li class="form-line" data-type="control_textbox" id="id_16"><label
						class="form-label form-label-left form-label-auto" id="label_16" for="input_16"> Insurance
						Provider: </label>
					<div id="cid_16" class="form-input jf-required"><input type="text" class=" form-textbox"
																		   data-type="input-textbox" id="input_16"
																		   name="q16_insuranceProvider16" size="40"
																		   value=""/></div>
				</li>
				<li class="form-line" data-type="control_textbox" id="id_17"><label
						class="form-label form-label-left form-label-auto" id="label_17" for="input_17"> Member
						ID#: </label>
					<div id="cid_17" class="form-input jf-required"><input type="text" class=" form-textbox"
																		   data-type="input-textbox" id="input_17"
																		   name="q17_memberId17" size="40" value=""/>
					</div>
				</li>
				<li class="form-line" data-type="control_textbox" id="id_18"><label
						class="form-label form-label-left form-label-auto" id="label_18" for="input_18"> Insurance Phone
						(if not Medicare): </label>
					<div id="cid_18" class="form-input jf-required"><input type="text" class=" form-textbox"
																		   data-type="input-textbox" id="input_18"
																		   name="q18_insurancePhone" size="40"
																		   value=""/></div>
				</li>
				<li class="form-line" data-type="control_textbox" id="id_30"><label
						class="form-label form-label-left form-label-auto" id="label_30" for="input_30"> Referring
						Doctor: </label>
					<div id="cid_30" class="form-input jf-required"><input type="text" class=" form-textbox"
																		   data-type="input-textbox" id="input_30"
																		   name="q30_referringDoctor30" size="20"
																		   value=""/></div>
				</li>
				<li class="form-line" data-type="control_textbox" id="id_31"><label
						class="form-label form-label-left form-label-auto" id="label_31" for="input_31"> Referring
						Doctor Phone: </label>
					<div id="cid_31" class="form-input jf-required"><input type="text" class=" form-textbox"
																		   data-type="input-textbox" id="input_31"
																		   name="q31_referringDoctor31" size="20"
																		   value=""/></div>
				</li>
				<li id="cid_32" class="form-input-wide" data-type="control_pagebreak">
					<div class="form-pagebreak">
						<div class="form-pagebreak-back-container">
							<button type="button" class="form-pagebreak-back " id="form-pagebreak-back_32"> Back
							</button>
						</div>
						<div class="form-pagebreak-next-container">
							<button type="button" class="form-pagebreak-next " id="form-pagebreak-next_32"> Next
							</button>
						</div>
					</div>
				</li>
			</ul>
			<ul class="form-section page-section" style="display:none;">
				<li class="form-line" data-type="control_text" id="id_33">
					<div id="cid_33" class="form-input-wide">
						<div id="text_33" class="form-html"><p>Lastly, let us know what products you are interested in
								and any additional information you would like to give us.</p></div>
					</div>
				</li>
				<li class="form-line" data-type="control_checkbox" id="id_19"><label
						class="form-label form-label-left form-label-auto" id="label_19" for="input_19"> Choose
						Any: </label>
					<div id="cid_19" class="form-input jf-required">
						<div class="form-single-column"><span class="form-checkbox-item" style="clear:left;"> <span
									class="dragger-item"> </span> <input type="checkbox" class="form-checkbox"
																		 id="input_19_0" name="q19_chooseAny19[]"
																		 value="Breast Care Products"/> <label
									id="label_input_19_0" for="input_19_0"> Breast Care Products </label> </span> <span
								class="form-checkbox-item" style="clear:left;"> <span
									class="dragger-item"> </span> <input type="checkbox" class="form-checkbox"
																		 id="input_19_1" name="q19_chooseAny19[]"
																		 value="Compression Products"/> <label
									id="label_input_19_1" for="input_19_1"> Compression Products </label> </span> <span
								class="form-checkbox-item" style="clear:left;"> <span
									class="dragger-item"> </span> <input type="checkbox" class="form-checkbox"
																		 id="input_19_2" name="q19_chooseAny19[]"
																		 value="Wigs"/> <label id="label_input_19_2"
																							   for="input_19_2"> Wigs </label> </span>
						</div>
					</div>
				</li>
				<li class="form-line" data-type="control_textarea" id="id_20"><label
						class="form-label form-label-left form-label-auto" id="label_20" for="input_20">
						Comment </label>
					<div id="cid_20" class="form-input jf-required"><textarea id="input_20" class="form-textarea"
																			  name="q20_comment" cols="40"
																			  rows="6"></textarea></div>
				</li>
			
				<li class="form-line" data-type="control_button" id="id_2">
					<div id="cid_2" class="form-input-wide">
											<div class="form-pagebreak-back-container">
							<button type="button" class="form-pagebreak-back " id="form-pagebreak-back_26"> Back
							</button>
						</div>
						<div style="margin-left:156px" class="form-buttons-wrapper">
							<button id="input_2" type="submit" class="form-submit-button"> Submit Form</button>
						</div>
					</div>
				</li>
			</ul>
		</div>

	</form>
            
          
!
            
              .jotform-form input {
  padding: 16px;
}

.jotform-form {
	background: #ffffff;
	margin: 5px;
	padding: 5px 10px 5px 10px;
}

.jotform-form li {
	margin-top: 20px;
}

.form-label {
	font-weight: 700;
}
.form-sub-label {
	font-size: 12px;
}

[data-type="control_text"] {
	line-height: 2;
}

[data-type="control_text"] strong {
	font-size: 24px;
}

.jotform-form [data-type="control_pagebreak"], .jotform-form [data-type="control_button"]{
	text-align: center;
	margin-top: 20px;
	margin-bottom: 20px;
}

[data-type^="control"] {
	display: -ms-flexbox;
	display: flex;
	-ms-flex-pack: justify;
	    justify-content: space-between;
}
[data-type^="control"] > label {
	display:inline-block;
	padding: 16px;
	font-size: 16px;
	vertical-align: top;
}

[data-type^="control"] > div {
	display:inline-block;
	-ms-flex-positive: 1;
	    flex-grow: 1;
}
[data-type="control_pagebreak"] div > div, [data-type="control_button"] div > div {
	display: inline-block;
	margin: 0 20px;
}
.form-sub-label-container {
	display: -ms-inline-flexbox;
	display: inline-flex;
	-ms-flex-direction: column;
	    flex-direction: column;
}

[data-type="control_fullname"] .form-sub-label-container {
	width: 49%;
}

[data-type="control_phone"] .form-sub-label-container:first-child {
	width: 30%;
}[data-type="control_phone"] .form-sub-label-container:first-child input {
	display: inline-block;
	width: 75%;
}
.jotform-form .showAutoCalendar, .jotform-form .date-separate, .jotform-form .phone-separate {
	display:none;
}
[data-type="control_phone"] .form-sub-label-container:last-child {
	width: 60%;
}
li.jf-required {
	position: relative;
}
.form-required {
	position: absolute;
	font-size: 12px;
	color: #ff3333;
	top: 30%;
	left: 0;
}
.form-checkbox-item {
	display: block;
}
.form-checkbox-item input{
	width: inherit;
}
label.error {
	-ms-flex-order: 99;
	    order: 99;
	display: -ms-flexbox;
	display: flex;
	color: #ff3333;
}

input.error {
	border: 1px solid #ff3333
}
            
          
!
            
              ( function ($) {


    var hidePage = function($page) {
        $page.slideUp();
    };

    var showPage = function($page) {
      $page.slideDown();
    };

    var backButtonEvent = function(e) {
        var $this = $(this);
        var page = $this.parents('ul').attr('data-page');
        page = (typeof page !== 'undefined') ? parseInt(page) : -1;
        if( page > 0 ) {
            hidePage($this.parents('ul'));
            showPage($('[data-page="' + (--page) +'"]'));
            
        }
    };

    var nextButtonEvent = function(e){
        var $this = $(this);

        var page = $this.parents('ul').attr('data-page');
        page = (typeof page !== 'undefined') ? parseInt(page) : -1;
        if($this.parents('form').valid()) {
            hidePage($this.parents('ul'));
            showPage($('[data-page="' + (++page) + '"]'));
            console.log('[data-page="' + (++page) + '"]');
            
        }
    };

    var initializeFormPages = function($formPages) {
        var numPages = $formPages.length;
        $formPages.each(function(i, page) {
           $(page).attr('data-page', i)       //add page number to each
               .removeAttr('style')           //remove existing styles
               .css('display','none');        //hide each page
            if (i === 0) {
                $(page).css('display','block');  //show first page
                $(page).find('.form-pagebreak-back-container').css('display','none');  //hide back button on first page
            } else if (i === numPages-1 ) {
                $(page).find('.form-pagebreak-next-container').css('display','none');  //hide next button on last page
            }

        });


    };

    $('document').ready(function() {
        var $form, $formPages;
        $form = $('.jotform-form');

        $form.find('span').removeAttr('style');  //remove any inline styles jotform adds

        $formPages = $form.find('.page-section');

        initializeFormPages($formPages);
        $('.form-pagebreak-back').on('click', backButtonEvent);
        $('.form-pagebreak-next').on('click', nextButtonEvent);


       $('form.jotform-form').validate({
          // ignore: ':hidden',
           rules: {
               'q3_name[first]' : {
                   required: true,
                   minlength: 2
               },
               'q3_name[last]' : {
                   required: true,
                   minlength: 2
               },
               'q29_phoneNumber[area]' : {
                   required: true,
                   minlength: 3,
                   number: true
               },
               'q4_email' : {
                   email: true
               },
               'q29_phoneNumber[phone]' : {
                   required: true
               },
               'q15_dateOf15[month]' : {
                   range: [1, 12]
               },
               'q15_dateOf15[day]' : {
                   range: [1, 31]
               },
               'q15_dateOf15[year]' : {
                   range: [1900, 2030]
               },
             'q20_comment' : {
               required: true,
               minlength: 2,
             }

           },
           messages: {
               'q3_name[first]' : {
                   required: "Please input your first name",
                   minlength: "Please type in your full first name"
               },
               'q3_name[last]' : {
                   required: "Please input your last name",
                   minlength: "Please type in your full last name"
               },
               'q29_phoneNumber[area]' : {
                   required: "3 digit area code",
                   minlength: "3 digit area code",
                   number: "3 digit area code"
               },
               'q29_phoneNumber[phone]' : {
                   required: "Please enter in your 7 digit phone number"
               },
               'q15_dateOf15[month]' : {
                   range: "Please enter month: 1 - 12"
               },
               'q15_dateOf15[day]' : {
                   range: "Please enter day: 1 - 31"
               },
               'q15_dateOf15[year]' : {
                   range: "Please enter a valid 4 digit year"
               }
           }
       });
        
    });
})(jQuery);

            
          
!
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