@import url(https://fonts.bunny.net/css?family=ibm-plex-sans:400,600); #_form_1_ { font-size:14px; line-height:1.6; font-family:arial, helvetica, sans-serif; margin:0; } #_form_1_ * { outline:0; } ._form_hide { display:none; visibility:hidden; } ._form_show { display:block; visibility:visible; } #_form_1_._form-top { top:0; } #_form_1_._form-bottom { bottom:0; } #_form_1_._form-left { left:0; } #_form_1_._form-right { right:0; } #_form_1_ input[type="text"],#_form_1_ input[type="tel"],#_form_1_ input[type="date"],#_form_1_ textarea { padding:6px; height:auto; border:#979797 1px solid; border-radius:4px; color:#000 !important; font-size:14px; -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; } #_form_1_ textarea { resize:none; } #_form_1_ ._submit { -webkit-appearance:none; cursor:pointer; font-family:arial, sans-serif; font-size:14px; text-align:center; background:#9802a3 !important; border:0 !important; -moz-border-radius:4px !important; -webkit-border-radius:4px !important; border-radius:4px !important; color:#fff !important; padding:10px !important; } #_form_1_ ._submit:disabled { cursor:not-allowed; opacity:0.4; } #_form_1_ ._submit.processing { position:relative; } #_form_1_ ._submit.processing::before { content:''; width:1em; height:1em; position:absolute; z-index:1; top:50%; left:50%; border:double 3px transparent; border-radius:50%; background-image:linear-gradient(#9802a3, #9802a3), conic-gradient(#9802a3, #fff); background-origin:border-box; background-clip:content-box, border-box; animation:1200ms ease 0s infinite normal none running _spin; } #_form_1_ ._submit.processing::after { content:''; position:absolute; top:0; bottom:0; left:0; right:0; background:#9802a3 !important; border:0 !important; -moz-border-radius:4px !important; -webkit-border-radius:4px !important; border-radius:4px !important; color:#fff !important; padding:10px !important; } @keyframes _spin { 0% { transform:translate(-50%, -50%) rotate(90deg); } 100% { transform:translate(-50%, -50%) rotate(450deg); } } #_form_1_ ._close-icon { cursor:pointer; background-image:url('https://d226aj4ao1t61q.cloudfront.net/esfkyjh1u_forms-close-dark.png'); background-repeat:no-repeat; background-size:14.2px 14.2px; position:absolute; display:block; top:11px; right:9px; overflow:hidden; width:16.2px; height:16.2px; } #_form_1_ ._close-icon:before { position:relative; } #_form_1_ ._form-body { margin-bottom:30px; } #_form_1_ ._form-image-left { width:150px; float:left; } #_form_1_ ._form-content-right { margin-left:164px; } #_form_1_ ._form-branding { color:#fff; font-size:10px; clear:both; text-align:left; margin-top:30px; font-weight:100; } #_form_1_ ._form-branding ._logo { display:block; width:130px; height:14px; margin-top:6px; background-image:url('https://d226aj4ao1t61q.cloudfront.net/hh9ujqgv5_aclogo_li.png'); background-size:130px auto; background-repeat:no-repeat; } #_form_1_ .form-sr-only { position:absolute; width:1px; height:1px; padding:0; margin:-1px; overflow:hidden; clip:rect(0, 0, 0, 0); border:0; } #_form_1_ ._form-label,#_form_1_ ._form_element ._form-label { font-weight:bold; margin-bottom:5px; display:block; } #_form_1_._dark ._form-branding { color:#333; } #_form_1_._dark ._form-branding ._logo { background-image:url('https://d226aj4ao1t61q.cloudfront.net/jftq2c8s_aclogo_dk.png'); } #_form_1_ ._form_element { position:relative; margin-bottom:10px; font-size:0; max-width:100%; } #_form_1_ ._form_element * { font-size:14px; } #_form_1_ ._form_element._clear { clear:both; width:100%; float:none; } #_form_1_ ._form_element._clear:after { clear:left; } #_form_1_ ._form_element input[type="text"],#_form_1_ ._form_element input[type="date"],#_form_1_ ._form_element select,#_form_1_ ._form_element textarea:not(.g-recaptcha-response) { display:block; width:100%; -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; font-family:inherit; } #_form_1_ ._field-wrapper { position:relative; } #_form_1_ ._inline-style { float:left; } #_form_1_ ._inline-style input[type="text"] { width:150px; } #_form_1_ ._inline-style:not(._clear) + ._inline-style:not(._clear) { margin-left:20px; } #_form_1_ ._form_element img._form-image { max-width:100%; } #_form_1_ ._form_element ._form-fieldset { border:0; padding:0.01em 0 0 0; margin:0; min-width:0; } #_form_1_ ._clear-element { clear:left; } #_form_1_ ._full_width { width:100%; } #_form_1_ ._form_full_field { display:block; width:100%; margin-bottom:10px; } #_form_1_ input[type="text"]._has_error,#_form_1_ textarea._has_error { border:#f37c7b 1px solid; } #_form_1_ input[type="checkbox"]._has_error { outline:#f37c7b 1px solid; } #_form_1_ ._error { display:block; position:absolute; font-size:14px; z-index:10000001; } #_form_1_ ._error._above { padding-bottom:4px; bottom:39px; right:0; } #_form_1_ ._error._below { padding-top:8px; top:100%; right:0; } #_form_1_ ._error._above ._error-arrow { bottom:-4px; right:15px; border-left:8px solid transparent; border-right:8px solid transparent; border-top:8px solid #fdd; } #_form_1_ ._error._below ._error-arrow { top:0; right:15px; border-left:8px solid transparent; border-right:8px solid transparent; border-bottom:8px solid #fdd; } #_form_1_ ._error-inner { padding:12px 12px 12px 36px; background-color:#fdd; background-image:url("data:image/svg+xml,%3Csvg width='16' height='16' viewBox='0 0 16 16' fill='none' xmlns='https://www.w3.org/2000/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M16 8C16 12.4183 12.4183 16 8 16C3.58172 16 0 12.4183 0 8C0 3.58172 3.58172 0 8 0C12.4183 0 16 3.58172 16 8ZM9 3V9H7V3H9ZM9 13V11H7V13H9Z' fill='%23CA0000'/%3E%3C/svg%3E"); background-repeat:no-repeat; background-position:12px center; font-size:14px; font-family:arial, sans-serif; font-weight:600; line-height:16px; color:#000; text-align:center; text-decoration:none; -webkit-border-radius:4px; -moz-border-radius:4px; border-radius:4px; box-shadow:0px 1px 4px rgba(31, 33, 41, 0.298295); } #_form_1_ ._error-inner._form_error { margin-bottom:5px; text-align:left; } #_form_1_ ._button-wrapper ._error-inner._form_error { position:static; } #_form_1_ ._error-inner._no_arrow { margin-bottom:10px; } #_form_1_ ._error-arrow { position:absolute; width:0; height:0; } #_form_1_ ._error-html { margin-bottom:10px; } .pika-single { z-index:10000001 !important; } #_form_1_ input[type="text"].datetime_date { width:69%; display:inline; } #_form_1_ select.datetime_time { width:29%; display:inline; height:32px; } #_form_1_ input[type="date"].datetime_date { width:69%; display:inline-flex; } #_form_1_ input[type="time"].datetime_time { width:29%; display:inline-flex; } @media all and (min-width:320px) and (max-width:667px) { ::-webkit-scrollbar { display:none; } #_form_1_ { margin:0; width:100%; min-width:100%; max-width:100%; box-sizing:border-box; } #_form_1_ * { -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; font-size:1em; } #_form_1_ ._form-content { margin:0; width:100%; } #_form_1_ ._form-inner { display:block; min-width:100%; } #_form_1_ ._form-title,#_form_1_ ._inline-style { margin-top:0; margin-right:0; margin-left:0; } #_form_1_ ._form-title { font-size:1.2em; } #_form_1_ ._form_element { margin:0 0 20px; padding:0; width:100%; } #_form_1_ ._form-element,#_form_1_ ._inline-style,#_form_1_ input[type="text"],#_form_1_ label,#_form_1_ p,#_form_1_ textarea:not(.g-recaptcha-response) { float:none; display:block; width:100%; } #_form_1_ ._row._checkbox-radio label { display:inline; } #_form_1_ ._row,#_form_1_ p,#_form_1_ label { margin-bottom:0.7em; width:100%; } #_form_1_ ._row input[type="checkbox"],#_form_1_ ._row input[type="radio"] { margin:0 !important; vertical-align:middle !important; } #_form_1_ ._row input[type="checkbox"] + span label { display:inline; } #_form_1_ ._row span label { margin:0 !important; width:initial !important; vertical-align:middle !important; } #_form_1_ ._form-image { max-width:100%; height:auto !important; } #_form_1_ input[type="text"] { padding-left:10px; padding-right:10px; font-size:16px; line-height:1.3em; -webkit-appearance:none; } #_form_1_ input[type="radio"],#_form_1_ input[type="checkbox"] { display:inline-block; width:1.3em; height:1.3em; font-size:1em; margin:0 0.3em 0 0; vertical-align:baseline; } #_form_1_ button[type="submit"] { padding:20px; font-size:1.5em; } #_form_1_ ._inline-style { margin:20px 0 0 !important; } } #_form_1_ { position:relative; text-align:left; margin:25px auto 0; padding-top:20px; padding-right:20px; padding-bottom:20px; padding-left:20px; -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; *zoom:1; background:#fff !important; border:0px solid #b0b0b0 !important; max-width:500px; -moz-border-radius:0px !important; -webkit-border-radius:0px !important; border-radius:0px !important; color:#000 !important; } #_form_1_._inline-form,#_form_1_._inline-form ._form-content,#_form_1_._inline-form input,#_form_1_._inline-form ._submit { font-family:"IBM Plex Sans", Helvetica, sans-serif; } #_form_1_ ._form-title { font-size:22px; line-height:normal; font-weight:600; margin-bottom:0; } #_form_1_:before,#_form_1_:after { content:" "; display:table; } #_form_1_:after { clear:both; } #_form_1_._inline-style { width:auto; display:inline-block; } #_form_1_._inline-style input[type="text"],#_form_1_._inline-style input[type="date"] { padding:10px 12px; } #_form_1_._inline-style button._inline-style { position:relative; top:27px; } #_form_1_._inline-style p { margin:0; } #_form_1_._inline-style ._button-wrapper { position:relative; margin:27px 12.5px 0 20px; } #_form_1_ ._form-thank-you { position:relative; left:0; right:0; text-align:center; font-size:18px; } @media all and (min-width:320px) and (max-width:667px) { #_form_1_._inline-form._inline-style ._inline-style._button-wrapper { margin-top:20px !important; margin-left:0 !important; } } #_form_1_ .iti.iti--allow-dropdown.iti--separate-dial-code { width:100%; } #_form_1_ .iti input { width:100%; height:32px; border:#979797 1px solid; border-radius:4px; } #_form_1_ .iti--separate-dial-code .iti__selected-flag { background-color:#fff; border-radius:4px; } #_form_1_ .iti--separate-dial-code .iti__selected-flag:hover { background-color:rgba(0, 0, 0, 0.05); } #_form_1_ .iti__country-list { border-radius:4px; margin-top:4px; min-width:460px; } #_form_1_ .iti__country-list--dropup { margin-bottom:4px; } #_form_1_ .phone-error-hidden { display:none; } #_form_1_ .phone-error { color:#e40e49; } #_form_1_ .phone-input-error { border:1px solid #e40e49 !important; } window.cfields = {"5":"how_can_we_help_please_send_over_all_your_questions"}; window._show_thank_you = function(id, message, trackcmp_url, email) { var form = document.getElementById('_form_' + id + '_'), thank_you = form.querySelector('._form-thank-you'); form.querySelector('._form-content').style.display = 'none'; thank_you.innerHTML = message; thank_you.style.display = 'block'; const vgoAlias = typeof visitorGlobalObjectAlias === 'undefined' ? 'vgo' : visitorGlobalObjectAlias; var visitorObject = window[vgoAlias]; if (email && typeof visitorObject !== 'undefined') { visitorObject('setEmail', email); visitorObject('update'); } else if (typeof(trackcmp_url) != 'undefined' && trackcmp_url) { // Site tracking URL to use after inline form submission. _load_script(trackcmp_url); } if (typeof window._form_callback !== 'undefined') window._form_callback(id); }; window._show_error = function(id, message, html) { var form = document.getElementById('_form_' + id + '_'), err = document.createElement('div'), button = form.querySelector('button'), old_error = form.querySelector('._form_error'); if (old_error) old_error.parentNode.removeChild(old_error); err.innerHTML = message; err.className = '_error-inner _form_error _no_arrow'; var wrapper = document.createElement('div'); wrapper.className = '_form-inner'; wrapper.appendChild(err); button.parentNode.insertBefore(wrapper, button); var submitButton = form.querySelector('[id^="_form"][id$="_submit"]'); submitButton.disabled = false; submitButton.classList.remove('processing'); if (html) { var div = document.createElement('div'); div.className = '_error-html'; div.innerHTML = html; err.appendChild(div); } }; window._load_script = function(url, callback, isSubmit) { var head = document.querySelector('head'), script = document.createElement('script'), r = false; var submitButton = document.querySelector('#_form_1_submit'); script.type = 'text/javascript'; script.charset = 'utf-8'; script.src = url; if (callback) { script.onload = script.onreadystatechange = function() { if (!r && (!this.readyState || this.readyState == 'complete')) { r = true; callback(); } }; } script.onerror = function() { if (isSubmit) { if (script.src.length > 10000) { _show_error("1", "Sorry, your submission failed. Please shorten your responses and try again."); } else { _show_error("1", "Sorry, your submission failed. Please try again."); } submitButton.disabled = false; submitButton.classList.remove('processing'); } } head.appendChild(script); }; (function() { if (window.location.search.search("excludeform") !== -1) return false; var getCookie = function(name) { var match = document.cookie.match(new RegExp('(^|; )' + name + '=([^;]+)')); return match ? match[2] : null; } var setCookie = function(name, value) { var now = new Date(); var time = now.getTime(); var expireTime = time + 1000 * 60 * 60 * 24 * 365; now.setTime(expireTime); document.cookie = name + '=' + value + '; expires=' + now + ';path=/; Secure; SameSite=Lax;'; } var addEvent = function(element, event, func) { if (element.addEventListener) { element.addEventListener(event, func); } else { var oldFunc = element['on' + event]; element['on' + event] = function() { oldFunc.apply(this, arguments); func.apply(this, arguments); }; } } var _removed = false; var form_to_submit = document.getElementById('_form_1_'); var allInputs = form_to_submit.querySelectorAll('input, select, textarea'), tooltips = [], submitted = false; var getUrlParam = function(name) { var params = new URLSearchParams(window.location.search); return params.get(name) || false; }; var acctDateFormat = "%d/%m/%Y"; var getNormalizedDate = function(date, acctFormat) { var decodedDate = decodeURIComponent(date); if (acctFormat && acctFormat.match(/(%d|%e).*%m/gi) !== null) { return decodedDate.replace(/(\d{2}).*(\d{2}).*(\d{4})/g, '$3-$2-$1'); } else if (Date.parse(decodedDate)) { var dateObj = new Date(decodedDate); var year = dateObj.getFullYear(); var month = dateObj.getMonth() + 1; var day = dateObj.getDate(); return `${year}-${month < 10 ? `0${month}` : month}-${day < 10 ? `0${day}` : day}`; } return false; }; var getNormalizedTime = function(time) { var hour, minutes; var decodedTime = decodeURIComponent(time); var timeParts = Array.from(decodedTime.matchAll(/(\d{1,2}):(\d{1,2})\W*([AaPp][Mm])?/gm))[0]; if (timeParts[3]) { // 12 hour format var isPM = timeParts[3].toLowerCase() === 'pm'; if (isPM) { hour = parseInt(timeParts[1]) === 12 ? '12' : `${parseInt(timeParts[1]) + 12}`; } else { hour = parseInt(timeParts[1]) === 12 ? '0' : timeParts[1]; } } else { // 24 hour format hour = timeParts[1]; } var normalizedHour = parseInt(hour) < 10 ? `0${parseInt(hour)}` : hour; var minutes = timeParts[2]; return `${normalizedHour}:${minutes}`; }; for (var i = 0; i < allInputs.length; i++) { var regexStr = "field\\[(\\d+)\\]"; var results = new RegExp(regexStr).exec(allInputs[i].name); if (results != undefined) { allInputs[i].dataset.name = allInputs[i].name.match(/\[time\]$/) ? `${window.cfields[results[1]]}_time` : window.cfields[results[1]]; } else { allInputs[i].dataset.name = allInputs[i].name; } var fieldVal = getUrlParam(allInputs[i].dataset.name); if (fieldVal) { if (allInputs[i].dataset.autofill === "false") { continue; } if (allInputs[i].type == "radio" || allInputs[i].type == "checkbox") { if (allInputs[i].value == fieldVal) { allInputs[i].checked = true; } } else if (allInputs[i].type == "date") { allInputs[i].value = getNormalizedDate(fieldVal, acctDateFormat); } else if (allInputs[i].type == "time") { allInputs[i].value = getNormalizedTime(fieldVal); } else { allInputs[i].value = fieldVal; } } } var remove_tooltips = function() { for (var i = 0; i < tooltips.length; i++) { tooltips[i].tip.parentNode.removeChild(tooltips[i].tip); } tooltips = []; }; var remove_tooltip = function(elem) { for (var i = 0; i < tooltips.length; i++) { if (tooltips[i].elem === elem) { tooltips[i].tip.parentNode.removeChild(tooltips[i].tip); tooltips.splice(i, 1); return; } } }; var create_tooltip = function(elem, text) { var tooltip = document.createElement('div'), arrow = document.createElement('div'), inner = document.createElement('div'), new_tooltip = {}; if (elem.type != 'radio' && elem.type != 'checkbox') { tooltip.className = '_error'; arrow.className = '_error-arrow'; inner.className = '_error-inner'; inner.innerHTML = text; tooltip.appendChild(arrow); tooltip.appendChild(inner); elem.parentNode.appendChild(tooltip); } else { tooltip.className = '_error-inner _no_arrow'; tooltip.innerHTML = text; elem.parentNode.insertBefore(tooltip, elem); new_tooltip.no_arrow = true; } new_tooltip.tip = tooltip; new_tooltip.elem = elem; tooltips.push(new_tooltip); return new_tooltip; }; var resize_tooltip = function(tooltip) { var rect = tooltip.elem.getBoundingClientRect(); var doc = document.documentElement, scrollPosition = rect.top - ((window.pageYOffset || doc.scrollTop) - (doc.clientTop || 0)); if (scrollPosition < 40) { tooltip.tip.className = tooltip.tip.className.replace(/ ?(_above|_below) ?/g, '') + ' _below'; } else { tooltip.tip.className = tooltip.tip.className.replace(/ ?(_above|_below) ?/g, '') + ' _above'; } }; var resize_tooltips = function() { if (_removed) return; for (var i = 0; i < tooltips.length; i++) { if (!tooltips[i].no_arrow) resize_tooltip(tooltips[i]); } }; var validate_field = function(elem, remove) { var tooltip = null, value = elem.value, no_error = true; remove ? remove_tooltip(elem) : false; if (elem.type != 'checkbox') elem.className = elem.className.replace(/ ?_has_error ?/g, ''); if (elem.getAttribute('required') !== null) { if (elem.type == 'radio' || (elem.type == 'checkbox' && /any/.test(elem.className))) { var elems = form_to_submit.elements[elem.name]; if (!(elems instanceof NodeList || elems instanceof HTMLCollection) || elems.length 31 && (charCode < 48 || charCode > 57) && charCode !== 8) { e.preventDefault(); } }); }; var showPhoneInputError = function(inputId) { var errorMessage = document.getElementById("error-msg-" + inputId); var input = document.getElementById(inputId); errorMessage.classList.add("phone-error"); errorMessage.classList.remove("phone-error-hidden"); input.classList.add("phone-input-error"); }; window['recaptcha_callback'] = function() { // Get all recaptchas in the DOM (there may be more than one form on the page). var recaptchas = document.getElementsByClassName("g-recaptcha"); for (var i in recaptchas) { // Set the recaptcha element ID, so the recaptcha can be applied to each element. var recaptcha_id = "recaptcha_" + i; recaptchas[i].id = recaptcha_id; var el = document.getElementById(recaptcha_id); if (el != null) { var sitekey = el.getAttribute("data-sitekey"); var stoken = el.getAttribute("data-stoken"); grecaptcha.render(recaptcha_id, {"sitekey":sitekey,"stoken":stoken}); } } }; _load_script( "https://www.google.com/recaptcha/api.js?onload=recaptcha_callback&render=explicit" ); var _form_serialize = function(form){if(!form||form.nodeName!=="FORM"){return }var i,j,q=[];for(i=0;i { eval(data.js); }); } else { _load_script('https://clinicsoftwarerevolution.activehosted.com/proc.php?' + serialized + '&jsonp=true', null, true); } } return false; }; addEvent(form_to_submit, 'submit', form_submit); })();

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