window.enableEventObserver=true JotForm.newDefaultTheme = true; JotForm.extendsNewTheme = false; JotForm.singleProduct = false; JotForm.newPaymentUIForNewCreatedForms = true; JotForm.texts = {"confirmEmail":"E-mail does not match","pleaseWait":"Please wait...","validateEmail":"You need to validate this e-mail","confirmClearForm":"Are you sure you want to clear the form","lessThan":"Your score should be less than or equal to","incompleteFields":"There are incomplete required fields. Please complete them.","required":"This field is required.","requireOne":"At least one field required.","requireEveryRow":"Every row is required.","requireEveryCell":"Every cell is required.","email":"Enter a valid e-mail address","alphabetic":"This field can only contain letters","numeric":"This field can only contain numeric values","alphanumeric":"This field can only contain letters and numbers.","cyrillic":"This field can only contain cyrillic characters","url":"This field can only contain a valid URL","currency":"This field can only contain currency values.","fillMask":"Field value must fill mask.","uploadExtensions":"You can only upload following files:","noUploadExtensions":"File has no extension file type (e.g. .txt, .png, .jpeg)","uploadFilesize":"File size cannot be bigger than:","uploadFilesizemin":"File size cannot be smaller than:","gradingScoreError":"Score total should only be less than or equal to","inputCarretErrorA":"Input should not be less than the minimum value:","inputCarretErrorB":"Input should not be greater than the maximum value:","maxDigitsError":"The maximum digits allowed is","minCharactersError":"The number of characters should not be less than the minimum value:","maxCharactersError":"The number of characters should not be more than the maximum value:","freeEmailError":"Free email accounts are not allowed","minSelectionsError":"The minimum required number of selections is ","maxSelectionsError":"The maximum number of selections allowed is ","pastDatesDisallowed":"Date must not be in the past.","dateLimited":"This date is unavailable.","dateInvalid":"This date is not valid. The date format is {format}","dateInvalidSeparate":"This date is not valid. Enter a valid {element}.","ageVerificationError":"You must be older than {minAge} years old to submit this form.","multipleFileUploads_typeError":"{file} has invalid extension. Only {extensions} are allowed.","multipleFileUploads_sizeError":"{file} is too large, maximum file size is {sizeLimit}.","multipleFileUploads_minSizeError":"{file} is too small, minimum file size is {minSizeLimit}.","multipleFileUploads_emptyError":"{file} is empty, please select files again without it.","multipleFileUploads_uploadFailed":"File upload failed, please remove it and upload the file again.","multipleFileUploads_onLeave":"The files are being uploaded, if you leave now the upload will be cancelled.","multipleFileUploads_fileLimitError":"Only {fileLimit} file uploads allowed.","dragAndDropFilesHere_infoMessage":"Drag and drop files here","chooseAFile_infoMessage":"Choose a file","maxFileSize_infoMessage":"Max. file size","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing.","wordLimitError":"Too many words. The limit is","wordMinLimitError":"Too few words. The minimum is","characterLimitError":"Too many Characters. The limit is","characterMinLimitError":"Too few characters. The minimum is","ccInvalidNumber":"Credit Card Number is invalid.","ccInvalidCVC":"CVC number is invalid.","ccInvalidExpireDate":"Expire date is invalid.","ccInvalidExpireMonth":"Expiration month is invalid.","ccInvalidExpireYear":"Expiration year is invalid.","ccMissingDetails":"Please fill up the credit card details.","ccMissingProduct":"Please select at least one product.","ccMissingDonation":"Please enter numeric values for donation amount.","disallowDecimals":"Please enter a whole number.","restrictedDomain":"This domain is not allowed","ccDonationMinLimitError":"Minimum amount is {minAmount} {currency}","requiredLegend":"All fields marked with * are required and must be filled.","geoPermissionTitle":"Permission Denied","geoPermissionDesc":"Check your browser's privacy settings.","geoNotAvailableTitle":"Position Unavailable","geoNotAvailableDesc":"Location provider not available. Please enter the address manually.","geoTimeoutTitle":"Timeout","geoTimeoutDesc":"Please check your internet connection and try again.","selectedTime":"Selected Time","formerSelectedTime":"Former Time","cancelAppointment":"Cancel Appointment","cancelSelection":"Cancel Selection","noSlotsAvailable":"No slots available","slotUnavailable":"{time} on {date} has been selected is unavailable. Please select another slot.","multipleError":"There are {count} errors on this page. Please correct them before moving on.","oneError":"There is {count} error on this page. Please correct it before moving on.","doneMessage":"Well done! All errors are fixed.","invalidTime":"Enter a valid time","doneButton":"Done","reviewSubmitText":"Review and Submit","nextButtonText":"Next","prevButtonText":"Previous","seeErrorsButton":"See Errors","notEnoughStock":"Not enough stock for the current selection","notEnoughStock_remainedItems":"Not enough stock for the current selection ({count} items left)","soldOut":"Sold Out","justSoldOut":"Just Sold Out","selectionSoldOut":"Selection Sold Out","subProductItemsLeft":"({count} items left)","startButtonText":"START","submitButtonText":"Submit","submissionLimit":"Sorry! Only one entry is allowed.
Multiple submissions are disabled for this form.","reviewBackText":"Back to Form","seeAllText":"See All","progressMiddleText":"of","fieldError":"field has an error.","error":"Error"}; JotForm.newPaymentUI = true; JotForm.originalLanguage = "en"; JotForm.isFormViewTrackingAllowed = true; JotForm.replaceTagTest = true; JotForm.uploadServerURL = "https://upload.jotform.com/upload"; JotForm.clearFieldOnHide="disable"; JotForm.submitError="jumpToFirstError"; JotForm.isFullSource = true; JotForm.init(function(){ /*INIT-START*/ JotForm.setPhoneMaskingValidator( 'input_22_full', '\u0028\u0023\u0023\u0023\u0029 \u0023\u0023\u0023\u002d\u0023\u0023\u0023\u0023' ); if (window.JotForm && JotForm.accessible) $('input_24').setAttribute('tabindex',0); if (window.JotForm && JotForm.accessible) $('input_9').setAttribute('tabindex',0); if (window.JotForm && JotForm.accessible) $('input_23').setAttribute('tabindex',0); if (window.JotForm && JotForm.accessible) $('input_16').setAttribute('tabindex',0); JotForm.setCustomHint( 'input_16', 'i.e. Ground Floor, Retail, Medical Dental Building, Location Radius, Special Requests' ); JotForm.alterTexts({"ageVerificationError":"You must be older than {minAge} years old to submit this form.","alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","cancelAppointment":"Cancel Appointment","cancelSelection":"Cancel Selection","ccDonationMinLimitError":"Minimum amount is {minAmount} {currency}","ccInvalidCVC":"CVC number is invalid.","ccInvalidExpireDate":"Expire date is invalid.","ccInvalidExpireMonth":"Expiration month is invalid.","ccInvalidExpireYear":"Expiration year is invalid.","ccInvalidNumber":"Credit Card Number is invalid.","ccMissingDetails":"Please fill up the credit card details.","ccMissingDonation":"Please enter numeric values for donation amount.","ccMissingProduct":"Please select at least one product.","characterLimitError":"Too many Characters. The limit is","characterMinLimitError":"Too few characters. The minimum is","chooseAFile_infoMessage":"Choose a file","confirmClearForm":"Are you sure you want to clear the form","confirmEmail":"E-mail does not match","currency":"This field can only contain currency values.","cyrillic":"This field can only contain cyrillic characters","dateInvalid":"This date is not valid. The date format is {format}","dateInvalidSeparate":"This date is not valid. Enter a valid {element}.","dateLimited":"This date is unavailable.","disallowDecimals":"Please enter a whole number.","doneButton":"Done","doneMessage":"Well done! All errors are fixed.","dragAndDropFilesHere_infoMessage":"Drag and drop files here","email":"Enter a valid e-mail address","error":"Error","fieldError":"field has an error.","fillMask":"Field value must fill mask.","formerSelectedTime":"Former Time","freeEmailError":"Free email accounts are not allowed","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing.","geoNotAvailableDesc":"Location provider not available. Please enter the address manually.","geoNotAvailableTitle":"Position Unavailable","geoPermissionDesc":"Check your browser's privacy settings.","geoPermissionTitle":"Permission Denied","geoTimeoutDesc":"Please check your internet connection and try again.","geoTimeoutTitle":"Timeout","gradingScoreError":"Score total should only be less than or equal to","incompleteFields":"There are incomplete required fields. Please complete them.","inputCarretErrorA":"Input should not be less than the minimum value:","inputCarretErrorB":"Input should not be greater than the maximum value:","invalidTime":"Enter a valid time","justSoldOut":"Just Sold Out","lessThan":"Your score should be less than or equal to","maxCharactersError":"The number of characters should not be more than the maximum value:","maxDigitsError":"The maximum digits allowed is","maxFileSize_infoMessage":"Max. file size","maxSelectionsError":"The maximum number of selections allowed is ","minCharactersError":"The number of characters should not be less than the minimum value:","minSelectionsError":"The minimum required number of selections is ","multipleError":"There are {count} errors on this page. Please correct them before moving on.","multipleFileUploads_emptyError":"{file} is empty, please select files again without it.","multipleFileUploads_fileLimitError":"Only {fileLimit} file uploads allowed.","multipleFileUploads_minSizeError":"{file} is too small, minimum file size is {minSizeLimit}.","multipleFileUploads_onLeave":"The files are being uploaded, if you leave now the upload will be cancelled.","multipleFileUploads_sizeError":"{file} is too large, maximum file size is {sizeLimit}.","multipleFileUploads_typeError":"{file} has invalid extension. Only {extensions} are allowed.","multipleFileUploads_uploadFailed":"File upload failed, please remove it and upload the file again.","nextButtonText":"Next","noSlotsAvailable":"No slots available","notEnoughStock":"Not enough stock for the current selection","notEnoughStock_remainedItems":"Not enough stock for the current selection ({count} items left)","noUploadExtensions":"File has no extension file type (e.g. .txt, .png, .jpeg)","numeric":"This field can only contain numeric values","oneError":"There is {count} error on this page. Please correct it before moving on.","pastDatesDisallowed":"Date must not be in the past.","pleaseWait":"Please wait...","prevButtonText":"Previous","progressMiddleText":"of","required":"This field is required.","requiredLegend":"All fields marked with * are required and must be filled.","requireEveryCell":"Every cell is required.","requireEveryRow":"Every row is required.","requireOne":"At least one field required.","restrictedDomain":"This domain is not allowed","reviewBackText":"Back to Form","reviewSubmitText":"Review and Submit","seeAllText":"See All","seeErrorsButton":"See Errors","selectedTime":"Selected Time","selectionSoldOut":"Selection Sold Out","slotUnavailable":"{time} on {date} has been selected is unavailable. Please select another slot.","soldOut":"Sold Out","startButtonText":"START","submissionLimit":"Sorry! Only one entry is allowed. Multiple submissions are disabled for this form.","submitButtonText":"Submit","subProductItemsLeft":"({count} items left)","uploadExtensions":"You can only upload following files:","uploadFilesize":"File size cannot be bigger than:","uploadFilesizemin":"File size cannot be smaller than:","url":"This field can only contain a valid URL","validateEmail":"You need to validate this e-mail","wordLimitError":"Too many words. The limit is","wordMinLimitError":"Too few words. The minimum is"}); /*INIT-END*/ }); setTimeout(function() { JotForm.paymentExtrasOnTheFly([null,null,{"name":"submit2","qid":"2","text":"Submit","type":"control_button"},null,null,null,null,null,{"description":"","name":"fullName","qid":"8","text":"Full Name","type":"control_fullname"},{"description":"","name":"gpOr","qid":"9","subLabel":"","text":"GP or Specialty","type":"control_textbox"},null,null,null,null,null,null,{"description":"","mde":"No","name":"otherDetails","qid":"16","subLabel":"","text":"Other Details:","type":"control_textarea","wysiwyg":"Disable"},{"description":"","name":"wouldYou","qid":"17","text":"Would you like to request a demographics report for this location?","type":"control_radio"},null,null,{"description":"","name":"address","qid":"20","text":"Address","type":"control_address"},{"description":"","name":"email","qid":"21","subLabel":"example@example.com","text":"Email","type":"control_email"},{"description":"","name":"phoneNumber","qid":"22","text":"Phone Number","type":"control_phone"},{"description":"","name":"whenDoes","qid":"23","subLabel":"","text":"When Does Your Lease Expire?","type":"control_textbox"},{"description":"","name":"practiceName","qid":"24","subLabel":"","text":"Practice Name","type":"control_textbox"}]);}, 20); @media print{*{-webkit-print-color-adjust: exact !important;color-adjust: exact !important;}.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}} /* Injected CSS Code */ .form-label.form-label-auto { display: inline-block; float: left; text-align: left; } /* Injected CSS Code */ JotForm.showJotFormPowered = "0"; JotForm.poweredByText = "Powered by Jotform"; var all_spc = document.querySelectorAll("form[id='242535204372248'] .si" + "mple" + "_spc"); for (var i = 0; i < all_spc.length; i++) { all_spc[i].value = "242535204372248-242535204372248"; } JotForm.ownerView=true;JotForm.isNewSACL=true;