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html,
body {
margin: 0px;
}
#crmWebToEntityForm.zcwf_lblLeft {
width: 100%;
padding: 25px;
margin: 0 auto;
box-sizing: border-box;
}
#crmWebToEntityForm.zcwf_lblLeft * {
box-sizing: border-box;
}
#crmWebToEntityForm {
text-align: left;
}
#crmWebToEntityForm * {
direction: ltr;
}
.zcwf_lblLeft .zcwf_title {
word-wrap: break-word;
padding: 0px 6px 10px;
font-weight: bold;
}
.zcwf_lblLeft .zcwf_col_fld input[type=text],
.zcwf_lblLeft .zcwf_col_fld textarea {
width: 100%;
border: 1px solid #c0c6cc !important;
resize: vertical;
border-radius: 2px;
float: left;
}
.zcwf_lblLeft .zcwf_col_fld textarea {
height: 4em;
}
.zcwf_lblLeft .zcwf_col_lab {
width: 100%;
word-break: break-word;
padding: 0px 6px 0px;
margin-right: 10px;
margin-top: 5px;
float: left;
min-height: 1px;
}
.zcwf_lblLeft .zcwf_col_fld {
float: left;
width: 100%;
padding: 0px 6px 0px;
position: relative;
margin-top: 5px;
}
.zcwf_lblLeft .zcwf_privacy {
padding: 6px;
}
.zcwf_lblLeft .wfrm_fld_dpNn {
display: none;
}
.dIB {
display: inline-block;
}
.zcwf_lblLeft .zcwf_col_fld_slt {
width: 100%;
border: 1px solid #ccc;
background: #fff;
border-radius: 4px;
font-size: 12px;
float: left;
resize: vertical;
padding: 2px 5px;
}
.zcwf_lblLeft .zcwf_row:after,
.zcwf_lblLeft .zcwf_col_fld:after {
content: '';
display: table;
clear: both;
}
.zcwf_lblLeft .zcwf_col_help {
float: left;
margin-left: 7px;
font-size: 12px;
max-width: 35%;
word-break: break-word;
}
.zcwf_lblLeft .zcwf_help_icon {
cursor: pointer;
width: 16px;
height: 16px;
display: inline-block;
background: #fff;
border: 1px solid #c0c6cc;
color: #c1c1c1;
text-align: center;
font-size: 11px;
line-height: 16px;
font-weight: bold;
border-radius: 50%;
}
.zcwf_lblLeft .zcwf_row {
margin: 5px 0px;
}
.zcwf_lblLeft .formsubmit {
margin-right: 5px;
cursor: pointer;
color: var(--baseColor);
font-size: 12px;
}
.zcwf_lblLeft .zcwf_privacy_txt {
width: 90%;
color: rgb(0, 0, 0);
font-size: 12px;
font-family: Arial;
display: inline-block;
vertical-align: top;
color: var(--baseColor);
padding-top: 2px;
margin-left: 6px;
}
.zcwf_lblLeft .zcwf_button {
font-size: 16px;
color: var(--baseColor);
background-color: #f3f5f8;
border: 1px solid #f3f5f8;
padding: 13px 35px;
border-radius: 8px;
cursor: pointer;
max-width: 48%;
width: 100%;
margin: 0 0 10px 1%;
overflow: hidden;
text-overflow: ellipsis;
white-space: nowrap;
}
.zcwf_lblLeft .zcwf_button:hover {
background-color: rgba(243, 245, 248, 0.8);
border: 1px solid rgba(243, 245, 248, 0.8);
}
.zcwf_lblLeft .zcwf_tooltip_over {
position: relative;
}
.zcwf_lblLeft .zcwf_tooltip_ctn {
position: absolute;
background: #dedede;
padding: 3px 6px;
top: 3px;
border-radius: 4px;
word-break: break-word;
min-width: 100px;
max-width: 150px;
color: var(--baseColor);
z-index: 100;
}
.zcwf_lblLeft .zcwf_ckbox {
float: left;
}
.zcwf_lblLeft .zcwf_file {
width: 55%;
box-sizing: border-box;
float: left;
}
.clearB:after {
content: '';
display: block;
clear: both;
}
@media all and (max-width: 600px) {
.zcwf_lblLeft .zcwf_col_lab,
.zcwf_lblLeft .zcwf_col_fld {
width: auto;
float: none !important;
}
.zcwf_lblLeft .zcwf_col_help {
width: 40%;
}
}
function addAriaSelected6594890000000955001 (){
var optionElem = event.target;
var previousSelectedOption = optionElem.querySelector ( '[aria-selected=true]' );
if ( previousSelectedOption ){
previousSelectedOption.removeAttribute ( 'aria-selected' );
}
optionElem.querySelectorAll ( 'option' )[ optionElem.selectedIndex ].ariaSelected = 'true';
}
function privacyAlert6594890000000955001 (){
var privacyTool = document.getElementById ( 'privacyTool6594890000000955001' );
var privacyErr = document.getElementById ( 'privacyErr6594890000000955001' );
if ( privacyTool != undefined && !privacyTool.checked ){
privacyErr.style.visibility = 'visible';
privacyTool.ariaInvalid = 'true';
privacyTool.focus ();
return false;
}
return true;
}
function disableErr6594890000000955001 (){
var privacyTool = document.getElementById ( 'privacyTool6594890000000955001' );
var privacyErr = document.getElementById ( 'privacyErr6594890000000955001' );
if ( privacyTool != undefined && privacyTool.checked && privacyErr != undefined ){
privacyErr.style.visibility = 'hidden';
privacyTool.ariaInvalid = 'false';
}
}
/* Do not remove this code. */
function rccallback6594890000000955001 (){
if ( document.getElementById( 'recap6594890000000955001' ) != undefined ){
document.getElementById ( 'recap6594890000000955001' ).setAttribute ( 'captcha-verified', true );
}
if ( document.getElementById( 'recapErr6594890000000955001' ) != undefined && document.getElementById( 'recapErr6594890000000955001' ).style.visibility == 'visible' ){
document.getElementById ( 'recapErr6594890000000955001' ).style.visibility = 'hidden';
}
}
function reCaptchaAlert6594890000000955001 (){
var recap = document.getElementById ( 'recap6594890000000955001' );
if ( recap != undefined && recap.getAttribute( 'captcha-verified' ) == 'false' ){
document.getElementById ( 'recapErr6594890000000955001' ).style.visibility = 'visible';
return false;
}
return true;
}
function validateEmail6594890000000955001 (){
var form = document.forms[ 'WebToLeads6594890000000955001' ];
var emailFld = form.querySelectorAll ( '[ftype=email]' );
var i;
for ( i = 0; i < emailFld.length; i++ ){
var emailVal = emailFld[ i ].value;
if ((emailVal.replace( /^\s+|\s+$/g,'' )).length != 0 ){
var atpos = emailVal.indexOf ( '@' );
var dotpos = emailVal.lastIndexOf ( '.' );
if ( atpos < 1 || dotpos = emailVal.length ){
alert ( 'Please enter a valid email address. ' );
emailFld[ i ].focus ();
return false;
}
}
}
return true;
}
function checkMandatory6594890000000955001 (){
var mndFileds = new Array ( 'First Name', 'Last Name', 'Email', 'Mobile', 'LEADCF2', 'LEADCF3' );
var fldLangVal = new Array ( 'First\x20Name', 'Last\x20Name', 'Email', 'Mobile', 'Medical\x20Professional', 'Preferred\x20Location' );
for ( i = 0; i < mndFileds.length; i++ ){
var fieldObj = document.forms[ 'WebToLeads6594890000000955001' ][ mndFileds[ i ]];
if ( fieldObj ){
if (((fieldObj.value ).replace( /^\s+|\s+$/g,'' )).length == 0 ){
if ( fieldObj.type == 'file' ){
alert ( 'Please select a file to upload.' );
fieldObj.focus ();
return false;
}
alert ( fldLangVal[ i ] + ' cannot be empty.' );
fieldObj.focus ();
return false;
}
else if ( fieldObj.nodeName == 'SELECT' ){
if ( fieldObj.options[fieldObj.selectedIndex].value == '-None-' ){
alert ( fldLangVal[ i ] + ' cannot be none.' );
fieldObj.focus ();
return false;
}
}
else if ( fieldObj.type == 'checkbox' ){
if ( fieldObj.checked == false ){
alert ( 'Please accept ' + fldLangVal[ i ]);
fieldObj.focus ();
return false;
}
}
try {
if ( fieldObj.name == 'Last Name' ){
name = fieldObj.value;
}
}
catch ( e ){}
}
}
if ( !validateEmail6594890000000955001()){
return false;
}
if ( !privacyAlert6594890000000955001()){
return false;
}
if ( !reCaptchaAlert6594890000000955001()){
return false;
}
var urlparams = new URLSearchParams ( window.location.search );
if ( urlparams.has( 'service' ) && ( urlparams.get( 'service' ) === 'smarturl' )){
var webform = document.getElementById ( 'webform6594890000000955001' );
var service = urlparams.get ( 'service' );
var smarturlfield = document.createElement ( 'input' );
smarturlfield.setAttribute ( 'type', 'hidden' );
smarturlfield.setAttribute ( 'value', service );
smarturlfield.setAttribute ( 'name', 'service' );
webform.appendChild ( smarturlfield );
}
document.querySelector ( '.crmWebToEntityForm .formsubmit' ).setAttribute ( 'disabled', true );
}
function tooltipShow6594890000000955001 ( el ){
var tooltip = el.nextElementSibling;
var tooltipDisplay = tooltip.style.display;
if ( tooltipDisplay == 'none' ){
var allTooltip = document.getElementsByClassName ( 'zcwf_tooltip_over' );
for ( i = 0; i < allTooltip.length; i++ ){
allTooltip[ i ].style.display = 'none';
}
tooltip.style.display = 'block';
}
else {
tooltip.style.display = 'none';
}
}
-None-
Registered Doctor
Surgeon
Dermatologist
Dentist
Nurse
Pharmacist
Maxillofacial Surgeon
Other Healthcare Practitioner
-None-
New York
Dallas, Texas
Houston, Texas
Chicago, Illnois
Miami, Florida
Los Angeles, California
-None-
Employee Referral
External Referral
Advertisement
Cold Call
Facebook
LinkedIn
Website - Request A Callback
Existing Delegate Referral
Vilafortuney
WhatsApp
Website - Contact Us
Twitter
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